hospital_name last_updated_on version location_name hospital_address license_number|LA type_2_npi "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula." attester_name Specialists Hospital Shreveport 6/3/2026 3.0.0 Specialists Hospital Shreveport "1500 Line Ave, Shreveport, LOUISIANA 71101" 626 1912118134 TRUE description code|1 code|1|type code|2 code|2|type code|3 code|3|type modifiers setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name standard_charge|negotiated_dollar standard_charge|negotiated_percentage standard_charge|negotiated_algorithm median_amount 10th_percentile 90th_percentile count standard_charge|methodology standard_charge|min standard_charge|max additional_generic_notes ACE ELAST 4 (STERILE) 272 RC inpatient 131.24 65.62 BCBS Louisiana PPO 65.62 percent of total billed charges 65.62 111.55 50% of Eligible Charges ACE ELAST 4 (STERILE) 272 RC outpatient 131.24 104.99 BCBS Louisiana PPO 104.99 percent of total billed charges 72.18 111.55 80% of billed charge ACE ELAST 4 (STERILE) 272 RC outpatient 131.24 104.99 Cigna Commercial PPO 72.18 percent of total billed charges 72.18 111.55 55% of Billed Charges ACE ELAST 4 (STERILE) 272 RC inpatient 131.24 65.62 IMA of Louisiana Commercial PPO 111.55 percent of total billed charges 65.62 111.55 Inpatient Reimbursement at 85% of Billed Charges ACE ELAST 4 (STERILE) 272 RC outpatient 131.24 104.99 IMA of Louisiana Commercial PPO 111.55 percent of total billed charges 72.18 111.55 Reimbursement at 85% of billed charges ACE ELAST 4 (STERILE) 272 RC outpatient 131.24 104.99 Aetna Commercial PPO 72.18 percent of total billed charges 72.18 111.55 55 of billed Charges STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 123.69 61.85 BCBS Louisiana PPO 61.85 percent of total billed charges 61.85 105.14 50% of Eligible Charges STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 123.69 98.95 BCBS Louisiana PPO 98.95 percent of total billed charges 45.77 105.14 80% of billed charge STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 123.69 98.95 Cigna Commercial PPO 71.74 percent of total billed charges 45.77 105.14 58% of Billed Charges/$500 Threshold STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 123.69 61.85 IMA of Louisiana Commercial PPO 105.14 percent of total billed charges 61.85 105.14 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 123.69 98.95 IMA of Louisiana Commercial PPO 105.14 percent of total billed charges 45.77 105.14 Reimbursement at 85% of billed charges STEINMAN PIN 2.4MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 123.69 98.95 Aetna Commercial PPO 45.77 percent of total billed charges 45.77 105.14 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 FINGER SPLINT 2 270 RC inpatient 62.08 31.04 BCBS Louisiana PPO 31.04 percent of total billed charges 31.04 52.77 50% of Eligible Charges FINGER SPLINT 2 270 RC outpatient 62.08 49.66 BCBS Louisiana PPO 49.66 percent of total billed charges 34.14 52.77 80% of billed charge FINGER SPLINT 2 270 RC outpatient 62.08 49.66 Cigna Commercial PPO 34.14 percent of total billed charges 34.14 52.77 55% of Billed Charges FINGER SPLINT 2 270 RC inpatient 62.08 31.04 IMA of Louisiana Commercial PPO 52.77 percent of total billed charges 31.04 52.77 Inpatient Reimbursement at 85% of Billed Charges FINGER SPLINT 2 270 RC outpatient 62.08 49.66 IMA of Louisiana Commercial PPO 52.77 percent of total billed charges 34.14 52.77 Reimbursement at 85% of billed charges FINGER SPLINT 2 270 RC outpatient 62.08 49.66 Aetna Commercial PPO 34.14 percent of total billed charges 34.14 52.77 55 of billed Charges STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 141.96 70.98 BCBS Louisiana PPO 70.98 percent of total billed charges 70.98 120.67 50% of Eligible Charges STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 141.96 113.57 BCBS Louisiana PPO 113.57 percent of total billed charges 52.53 120.67 80% of billed charge STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 141.96 113.57 Cigna Commercial PPO 82.34 percent of total billed charges 52.53 120.67 58% of Billed Charges/$500 Threshold STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 141.96 70.98 IMA of Louisiana Commercial PPO 120.67 percent of total billed charges 70.98 120.67 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 141.96 113.57 IMA of Louisiana Commercial PPO 120.67 percent of total billed charges 52.53 120.67 Reimbursement at 85% of billed charges STEINMAN PIN 3.2MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 141.96 113.57 Aetna Commercial PPO 52.53 percent of total billed charges 52.53 120.67 37% Of Billed Charges 2000 BANDAGE ESMARK 4 272 RC inpatient 20.54 10.27 BCBS Louisiana PPO 10.27 percent of total billed charges 10.27 17.46 50% of Eligible Charges BANDAGE ESMARK 4 272 RC outpatient 20.54 16.43 BCBS Louisiana PPO 16.43 percent of total billed charges 11.3 17.46 80% of billed charge BANDAGE ESMARK 4 272 RC outpatient 20.54 16.43 Cigna Commercial PPO 11.3 percent of total billed charges 11.3 17.46 55% of Billed Charges BANDAGE ESMARK 4 272 RC inpatient 20.54 10.27 IMA of Louisiana Commercial PPO 17.46 percent of total billed charges 10.27 17.46 Inpatient Reimbursement at 85% of Billed Charges BANDAGE ESMARK 4 272 RC outpatient 20.54 16.43 IMA of Louisiana Commercial PPO 17.46 percent of total billed charges 11.3 17.46 Reimbursement at 85% of billed charges BANDAGE ESMARK 4 272 RC outpatient 20.54 16.43 Aetna Commercial PPO 11.3 percent of total billed charges 11.3 17.46 55 of billed Charges BASIN EMESIS 9 270 RC inpatient 117.8 58.9 BCBS Louisiana PPO 58.9 percent of total billed charges 58.9 100.13 50% of Eligible Charges BASIN EMESIS 9 270 RC outpatient 117.8 94.24 BCBS Louisiana PPO 94.24 percent of total billed charges 64.79 100.13 80% of billed charge BASIN EMESIS 9 270 RC outpatient 117.8 94.24 Cigna Commercial PPO 64.79 percent of total billed charges 64.79 100.13 55% of Billed Charges BASIN EMESIS 9 270 RC inpatient 117.8 58.9 IMA of Louisiana Commercial PPO 100.13 percent of total billed charges 58.9 100.13 Inpatient Reimbursement at 85% of Billed Charges BASIN EMESIS 9 270 RC outpatient 117.8 94.24 IMA of Louisiana Commercial PPO 100.13 percent of total billed charges 64.79 100.13 Reimbursement at 85% of billed charges BASIN EMESIS 9 270 RC outpatient 117.8 94.24 Aetna Commercial PPO 64.79 percent of total billed charges 64.79 100.13 55 of billed Charges DRILL BIT 3.5MM - SYNTHES 272 RC inpatient 227.5 113.75 BCBS Louisiana PPO 113.75 percent of total billed charges 113.75 193.38 50% of Eligible Charges DRILL BIT 3.5MM - SYNTHES 272 RC outpatient 227.5 182 BCBS Louisiana PPO 182 percent of total billed charges 125.13 193.38 80% of billed charge DRILL BIT 3.5MM - SYNTHES 272 RC outpatient 227.5 182 Cigna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55% of Billed Charges DRILL BIT 3.5MM - SYNTHES 272 RC inpatient 227.5 113.75 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 113.75 193.38 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 3.5MM - SYNTHES 272 RC outpatient 227.5 182 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 125.13 193.38 Reimbursement at 85% of billed charges DRILL BIT 3.5MM - SYNTHES 272 RC outpatient 227.5 182 Aetna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55 of billed Charges BLADE SURG 10 CARBON 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges BLADE SURG 10 CARBON 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge BLADE SURG 10 CARBON 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges BLADE SURG 10 CARBON 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges BLADE SURG 10 CARBON 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges BLADE SURG 10 CARBON 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges DERMABOND 272 RC inpatient 88.07 44.04 BCBS Louisiana PPO 44.04 percent of total billed charges 44.04 74.86 50% of Eligible Charges DERMABOND 272 RC outpatient 88.07 70.46 BCBS Louisiana PPO 70.46 percent of total billed charges 48.44 74.86 80% of billed charge DERMABOND 272 RC outpatient 88.07 70.46 Cigna Commercial PPO 48.44 percent of total billed charges 48.44 74.86 55% of Billed Charges DERMABOND 272 RC inpatient 88.07 44.04 IMA of Louisiana Commercial PPO 74.86 percent of total billed charges 44.04 74.86 Inpatient Reimbursement at 85% of Billed Charges DERMABOND 272 RC outpatient 88.07 70.46 IMA of Louisiana Commercial PPO 74.86 percent of total billed charges 48.44 74.86 Reimbursement at 85% of billed charges DERMABOND 272 RC outpatient 88.07 70.46 Aetna Commercial PPO 48.44 percent of total billed charges 48.44 74.86 55 of billed Charges DRAPE SHEET XLARGE 272 RC inpatient 16.04 8.02 BCBS Louisiana PPO 8.02 percent of total billed charges 8.02 13.63 50% of Eligible Charges DRAPE SHEET XLARGE 272 RC outpatient 16.04 12.83 BCBS Louisiana PPO 12.83 percent of total billed charges 8.82 13.63 80% of billed charge DRAPE SHEET XLARGE 272 RC outpatient 16.04 12.83 Cigna Commercial PPO 8.82 percent of total billed charges 8.82 13.63 55% of Billed Charges DRAPE SHEET XLARGE 272 RC inpatient 16.04 8.02 IMA of Louisiana Commercial PPO 13.63 percent of total billed charges 8.02 13.63 Inpatient Reimbursement at 85% of Billed Charges DRAPE SHEET XLARGE 272 RC outpatient 16.04 12.83 IMA of Louisiana Commercial PPO 13.63 percent of total billed charges 8.82 13.63 Reimbursement at 85% of billed charges DRAPE SHEET XLARGE 272 RC outpatient 16.04 12.83 Aetna Commercial PPO 8.82 percent of total billed charges 8.82 13.63 55 of billed Charges GLOVE BIOGEL SZ 9 272 RC inpatient 3.31 1.66 BCBS Louisiana PPO 1.66 percent of total billed charges 1.66 2.81 50% of Eligible Charges GLOVE BIOGEL SZ 9 272 RC outpatient 3.31 2.65 BCBS Louisiana PPO 2.65 percent of total billed charges 1.82 2.81 80% of billed charge GLOVE BIOGEL SZ 9 272 RC outpatient 3.31 2.65 Cigna Commercial PPO 1.82 percent of total billed charges 1.82 2.81 55% of Billed Charges GLOVE BIOGEL SZ 9 272 RC inpatient 3.31 1.66 IMA of Louisiana Commercial PPO 2.81 percent of total billed charges 1.66 2.81 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 9 272 RC outpatient 3.31 2.65 IMA of Louisiana Commercial PPO 2.81 percent of total billed charges 1.82 2.81 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 9 272 RC outpatient 3.31 2.65 Aetna Commercial PPO 1.82 percent of total billed charges 1.82 2.81 55 of billed Charges SAW BLADE #4118-137-090 272 RC inpatient 143.36 71.68 BCBS Louisiana PPO 71.68 percent of total billed charges 71.68 121.86 50% of Eligible Charges SAW BLADE #4118-137-090 272 RC outpatient 143.36 114.69 BCBS Louisiana PPO 114.69 percent of total billed charges 78.85 121.86 80% of billed charge SAW BLADE #4118-137-090 272 RC outpatient 143.36 114.69 Cigna Commercial PPO 78.85 percent of total billed charges 78.85 121.86 55% of Billed Charges SAW BLADE #4118-137-090 272 RC inpatient 143.36 71.68 IMA of Louisiana Commercial PPO 121.86 percent of total billed charges 71.68 121.86 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE #4118-137-090 272 RC outpatient 143.36 114.69 IMA of Louisiana Commercial PPO 121.86 percent of total billed charges 78.85 121.86 Reimbursement at 85% of billed charges SAW BLADE #4118-137-090 272 RC outpatient 143.36 114.69 Aetna Commercial PPO 78.85 percent of total billed charges 78.85 121.86 55 of billed Charges ELECTRODE BLADE #0012AM 272 RC inpatient 30.72 15.36 BCBS Louisiana PPO 15.36 percent of total billed charges 15.36 26.11 50% of Eligible Charges ELECTRODE BLADE #0012AM 272 RC outpatient 30.72 24.58 BCBS Louisiana PPO 24.58 percent of total billed charges 16.9 26.11 80% of billed charge ELECTRODE BLADE #0012AM 272 RC outpatient 30.72 24.58 Cigna Commercial PPO 16.9 percent of total billed charges 16.9 26.11 55% of Billed Charges ELECTRODE BLADE #0012AM 272 RC inpatient 30.72 15.36 IMA of Louisiana Commercial PPO 26.11 percent of total billed charges 15.36 26.11 Inpatient Reimbursement at 85% of Billed Charges ELECTRODE BLADE #0012AM 272 RC outpatient 30.72 24.58 IMA of Louisiana Commercial PPO 26.11 percent of total billed charges 16.9 26.11 Reimbursement at 85% of billed charges ELECTRODE BLADE #0012AM 272 RC outpatient 30.72 24.58 Aetna Commercial PPO 16.9 percent of total billed charges 16.9 26.11 55 of billed Charges GLOVE BIOGEL SZ 6.5 272 RC inpatient 4.05 2.03 BCBS Louisiana PPO 2.03 percent of total billed charges 2.03 3.44 50% of Eligible Charges GLOVE BIOGEL SZ 6.5 272 RC outpatient 4.05 3.24 BCBS Louisiana PPO 3.24 percent of total billed charges 2.23 3.44 80% of billed charge GLOVE BIOGEL SZ 6.5 272 RC outpatient 4.05 3.24 Cigna Commercial PPO 2.23 percent of total billed charges 2.23 3.44 55% of Billed Charges GLOVE BIOGEL SZ 6.5 272 RC inpatient 4.05 2.03 IMA of Louisiana Commercial PPO 3.44 percent of total billed charges 2.03 3.44 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 6.5 272 RC outpatient 4.05 3.24 IMA of Louisiana Commercial PPO 3.44 percent of total billed charges 2.23 3.44 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 6.5 272 RC outpatient 4.05 3.24 Aetna Commercial PPO 2.23 percent of total billed charges 2.23 3.44 55 of billed Charges GLOVE BIOGEL SZ 8.0 272 RC inpatient 4.19 2.1 BCBS Louisiana PPO 2.1 percent of total billed charges 2.1 3.56 50% of Eligible Charges GLOVE BIOGEL SZ 8.0 272 RC outpatient 4.19 3.35 BCBS Louisiana PPO 3.35 percent of total billed charges 2.3 3.56 80% of billed charge GLOVE BIOGEL SZ 8.0 272 RC outpatient 4.19 3.35 Cigna Commercial PPO 2.3 percent of total billed charges 2.3 3.56 55% of Billed Charges GLOVE BIOGEL SZ 8.0 272 RC inpatient 4.19 2.1 IMA of Louisiana Commercial PPO 3.56 percent of total billed charges 2.1 3.56 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 8.0 272 RC outpatient 4.19 3.35 IMA of Louisiana Commercial PPO 3.56 percent of total billed charges 2.3 3.56 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 8.0 272 RC outpatient 4.19 3.35 Aetna Commercial PPO 2.3 percent of total billed charges 2.3 3.56 55 of billed Charges GLOVE BIOGEL SZ 8.5 272 RC inpatient 4.04 2.02 BCBS Louisiana PPO 2.02 percent of total billed charges 2.02 3.43 50% of Eligible Charges GLOVE BIOGEL SZ 8.5 272 RC outpatient 4.04 3.23 BCBS Louisiana PPO 3.23 percent of total billed charges 2.22 3.43 80% of billed charge GLOVE BIOGEL SZ 8.5 272 RC outpatient 4.04 3.23 Cigna Commercial PPO 2.22 percent of total billed charges 2.22 3.43 55% of Billed Charges GLOVE BIOGEL SZ 8.5 272 RC inpatient 4.04 2.02 IMA of Louisiana Commercial PPO 3.43 percent of total billed charges 2.02 3.43 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 8.5 272 RC outpatient 4.04 3.23 IMA of Louisiana Commercial PPO 3.43 percent of total billed charges 2.22 3.43 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 8.5 272 RC outpatient 4.04 3.23 Aetna Commercial PPO 2.22 percent of total billed charges 2.22 3.43 55 of billed Charges GLOVE STERILE 7.0 LTX 272 RC inpatient 218.16 109.08 BCBS Louisiana PPO 109.08 percent of total billed charges 109.08 185.44 50% of Eligible Charges GLOVE STERILE 7.0 LTX 272 RC outpatient 218.16 174.53 BCBS Louisiana PPO 174.53 percent of total billed charges 119.99 185.44 80% of billed charge GLOVE STERILE 7.0 LTX 272 RC outpatient 218.16 174.53 Cigna Commercial PPO 119.99 percent of total billed charges 119.99 185.44 55% of Billed Charges GLOVE STERILE 7.0 LTX 272 RC inpatient 218.16 109.08 IMA of Louisiana Commercial PPO 185.44 percent of total billed charges 109.08 185.44 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 7.0 LTX 272 RC outpatient 218.16 174.53 IMA of Louisiana Commercial PPO 185.44 percent of total billed charges 119.99 185.44 Reimbursement at 85% of billed charges GLOVE STERILE 7.0 LTX 272 RC outpatient 218.16 174.53 Aetna Commercial PPO 119.99 percent of total billed charges 119.99 185.44 55 of billed Charges GOWN IMPERVIOUS XLG- RED/CHROME 272 RC inpatient 20.6 10.3 BCBS Louisiana PPO 10.3 percent of total billed charges 10.3 17.51 50% of Eligible Charges GOWN IMPERVIOUS XLG- RED/CHROME 272 RC outpatient 20.6 16.48 BCBS Louisiana PPO 16.48 percent of total billed charges 11.33 17.51 80% of billed charge GOWN IMPERVIOUS XLG- RED/CHROME 272 RC outpatient 20.6 16.48 Cigna Commercial PPO 11.33 percent of total billed charges 11.33 17.51 55% of Billed Charges GOWN IMPERVIOUS XLG- RED/CHROME 272 RC inpatient 20.6 10.3 IMA of Louisiana Commercial PPO 17.51 percent of total billed charges 10.3 17.51 Inpatient Reimbursement at 85% of Billed Charges GOWN IMPERVIOUS XLG- RED/CHROME 272 RC outpatient 20.6 16.48 IMA of Louisiana Commercial PPO 17.51 percent of total billed charges 11.33 17.51 Reimbursement at 85% of billed charges GOWN IMPERVIOUS XLG- RED/CHROME 272 RC outpatient 20.6 16.48 Aetna Commercial PPO 11.33 percent of total billed charges 11.33 17.51 55 of billed Charges IV CATH 20G X 1 1/4 272 RC inpatient 22 11 BCBS Louisiana PPO 11 percent of total billed charges 11 18.7 50% of Eligible Charges IV CATH 20G X 1 1/4 272 RC outpatient 22 17.6 BCBS Louisiana PPO 17.6 percent of total billed charges 12.1 18.7 80% of billed charge IV CATH 20G X 1 1/4 272 RC outpatient 22 17.6 Cigna Commercial PPO 12.1 percent of total billed charges 12.1 18.7 55% of Billed Charges IV CATH 20G X 1 1/4 272 RC inpatient 22 11 IMA of Louisiana Commercial PPO 18.7 percent of total billed charges 11 18.7 Inpatient Reimbursement at 85% of Billed Charges IV CATH 20G X 1 1/4 272 RC outpatient 22 17.6 IMA of Louisiana Commercial PPO 18.7 percent of total billed charges 12.1 18.7 Reimbursement at 85% of billed charges IV CATH 20G X 1 1/4 272 RC outpatient 22 17.6 Aetna Commercial PPO 12.1 percent of total billed charges 12.1 18.7 55 of billed Charges IV MICROBORE EXT SET W/ T 272 RC inpatient 411.6 205.8 BCBS Louisiana PPO 205.8 percent of total billed charges 205.8 349.86 50% of Eligible Charges IV MICROBORE EXT SET W/ T 272 RC outpatient 411.6 329.28 BCBS Louisiana PPO 329.28 percent of total billed charges 226.38 349.86 80% of billed charge IV MICROBORE EXT SET W/ T 272 RC outpatient 411.6 329.28 Cigna Commercial PPO 226.38 percent of total billed charges 226.38 349.86 55% of Billed Charges IV MICROBORE EXT SET W/ T 272 RC inpatient 411.6 205.8 IMA of Louisiana Commercial PPO 349.86 percent of total billed charges 205.8 349.86 Inpatient Reimbursement at 85% of Billed Charges IV MICROBORE EXT SET W/ T 272 RC outpatient 411.6 329.28 IMA of Louisiana Commercial PPO 349.86 percent of total billed charges 226.38 349.86 Reimbursement at 85% of billed charges IV MICROBORE EXT SET W/ T 272 RC outpatient 411.6 329.28 Aetna Commercial PPO 226.38 percent of total billed charges 226.38 349.86 55 of billed Charges KLING 4 CONFORM 272 RC inpatient 6.36 3.18 BCBS Louisiana PPO 3.18 percent of total billed charges 3.18 5.41 50% of Eligible Charges KLING 4 CONFORM 272 RC outpatient 6.36 5.09 BCBS Louisiana PPO 5.09 percent of total billed charges 3.5 5.41 80% of billed charge KLING 4 CONFORM 272 RC outpatient 6.36 5.09 Cigna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55% of Billed Charges KLING 4 CONFORM 272 RC inpatient 6.36 3.18 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.18 5.41 Inpatient Reimbursement at 85% of Billed Charges KLING 4 CONFORM 272 RC outpatient 6.36 5.09 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.5 5.41 Reimbursement at 85% of billed charges KLING 4 CONFORM 272 RC outpatient 6.36 5.09 Aetna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55 of billed Charges PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 511.18 255.59 BCBS Louisiana PPO 255.59 percent of total billed charges 255.59 434.5 50% of Eligible Charges PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 511.18 408.94 BCBS Louisiana PPO 408.94 percent of total billed charges 189.14 434.5 80% of billed charge PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 511.18 408.94 Cigna Commercial PPO 296.48 percent of total billed charges 189.14 434.5 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 511.18 255.59 IMA of Louisiana Commercial PPO 434.5 percent of total billed charges 255.59 434.5 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 511.18 408.94 IMA of Louisiana Commercial PPO 434.5 percent of total billed charges 189.14 434.5 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR LCP 7 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 511.18 408.94 Aetna Commercial PPO 189.14 percent of total billed charges 189.14 434.5 37% Of Billed Charges 2000 K-WIRE NON-THREADED .028 272 RC inpatient 150 75 BCBS Louisiana PPO 75 percent of total billed charges 75 127.5 50% of Eligible Charges K-WIRE NON-THREADED .028 272 RC outpatient 150 120 BCBS Louisiana PPO 120 percent of total billed charges 82.5 127.5 80% of billed charge K-WIRE NON-THREADED .028 272 RC outpatient 150 120 Cigna Commercial PPO 82.5 percent of total billed charges 82.5 127.5 55% of Billed Charges K-WIRE NON-THREADED .028 272 RC inpatient 150 75 IMA of Louisiana Commercial PPO 127.5 percent of total billed charges 75 127.5 Inpatient Reimbursement at 85% of Billed Charges K-WIRE NON-THREADED .028 272 RC outpatient 150 120 IMA of Louisiana Commercial PPO 127.5 percent of total billed charges 82.5 127.5 Reimbursement at 85% of billed charges K-WIRE NON-THREADED .028 272 RC outpatient 150 120 Aetna Commercial PPO 82.5 percent of total billed charges 82.5 127.5 55 of billed Charges SUTURE 3-0 ETHILON FSL 1671H 272 RC inpatient 8.75 4.38 BCBS Louisiana PPO 4.38 percent of total billed charges 4.38 7.44 50% of Eligible Charges SUTURE 3-0 ETHILON FSL 1671H 272 RC outpatient 8.75 7 BCBS Louisiana PPO 7 percent of total billed charges 4.81 7.44 80% of billed charge SUTURE 3-0 ETHILON FSL 1671H 272 RC outpatient 8.75 7 Cigna Commercial PPO 4.81 percent of total billed charges 4.81 7.44 55% of Billed Charges SUTURE 3-0 ETHILON FSL 1671H 272 RC inpatient 8.75 4.38 IMA of Louisiana Commercial PPO 7.44 percent of total billed charges 4.38 7.44 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 ETHILON FSL 1671H 272 RC outpatient 8.75 7 IMA of Louisiana Commercial PPO 7.44 percent of total billed charges 4.81 7.44 Reimbursement at 85% of billed charges SUTURE 3-0 ETHILON FSL 1671H 272 RC outpatient 8.75 7 Aetna Commercial PPO 4.81 percent of total billed charges 4.81 7.44 55 of billed Charges RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC inpatient 394.78 197.39 BCBS Louisiana PPO 197.39 percent of total billed charges 197.39 335.56 50% of Eligible Charges RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC outpatient 394.78 315.82 BCBS Louisiana PPO 315.82 percent of total billed charges 217.13 335.56 80% of billed charge RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC outpatient 394.78 315.82 Cigna Commercial PPO 217.13 percent of total billed charges 217.13 335.56 55% of Billed Charges RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC inpatient 394.78 197.39 IMA of Louisiana Commercial PPO 335.56 percent of total billed charges 197.39 335.56 Inpatient Reimbursement at 85% of Billed Charges RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC outpatient 394.78 315.82 IMA of Louisiana Commercial PPO 335.56 percent of total billed charges 217.13 335.56 Reimbursement at 85% of billed charges RASP RIORDAN (X-MAS TREE) 5100-37-126 272 RC outpatient 394.78 315.82 Aetna Commercial PPO 217.13 percent of total billed charges 217.13 335.56 55 of billed Charges RASP SM TEAR CROSS 5100-37-113 272 RC inpatient 373.45 186.73 BCBS Louisiana PPO 186.73 percent of total billed charges 186.73 317.43 50% of Eligible Charges RASP SM TEAR CROSS 5100-37-113 272 RC outpatient 373.45 298.76 BCBS Louisiana PPO 298.76 percent of total billed charges 205.4 317.43 80% of billed charge RASP SM TEAR CROSS 5100-37-113 272 RC outpatient 373.45 298.76 Cigna Commercial PPO 205.4 percent of total billed charges 205.4 317.43 55% of Billed Charges RASP SM TEAR CROSS 5100-37-113 272 RC inpatient 373.45 186.73 IMA of Louisiana Commercial PPO 317.43 percent of total billed charges 186.73 317.43 Inpatient Reimbursement at 85% of Billed Charges RASP SM TEAR CROSS 5100-37-113 272 RC outpatient 373.45 298.76 IMA of Louisiana Commercial PPO 317.43 percent of total billed charges 205.4 317.43 Reimbursement at 85% of billed charges RASP SM TEAR CROSS 5100-37-113 272 RC outpatient 373.45 298.76 Aetna Commercial PPO 205.4 percent of total billed charges 205.4 317.43 55 of billed Charges SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 DRAIN 10FR ROUND 272 RC inpatient 445.34 222.67 BCBS Louisiana PPO 222.67 percent of total billed charges 222.67 378.54 50% of Eligible Charges DRAIN 10FR ROUND 272 RC outpatient 445.34 356.27 BCBS Louisiana PPO 356.27 percent of total billed charges 244.94 378.54 80% of billed charge DRAIN 10FR ROUND 272 RC outpatient 445.34 356.27 Cigna Commercial PPO 244.94 percent of total billed charges 244.94 378.54 55% of Billed Charges DRAIN 10FR ROUND 272 RC inpatient 445.34 222.67 IMA of Louisiana Commercial PPO 378.54 percent of total billed charges 222.67 378.54 Inpatient Reimbursement at 85% of Billed Charges DRAIN 10FR ROUND 272 RC outpatient 445.34 356.27 IMA of Louisiana Commercial PPO 378.54 percent of total billed charges 244.94 378.54 Reimbursement at 85% of billed charges DRAIN 10FR ROUND 272 RC outpatient 445.34 356.27 Aetna Commercial PPO 244.94 percent of total billed charges 244.94 378.54 55 of billed Charges OBSERVATION FIRST HR G0378 HCPCS 762 RC inpatient 43.4 21.7 BCBS Louisiana PPO 21.7 percent of total billed charges 21.7 36.89 50% of Eligible Charges OBSERVATION FIRST HR G0378 HCPCS 762 RC outpatient 43.4 34.72 BCBS Louisiana PPO 34.72 percent of total billed charges 34.72 900 80% of billed charge OBSERVATION FIRST HR G0378 HCPCS 762 RC outpatient 43.4 34.72 Cigna Commercial PPO 900 other 34.72 900 900 per stay OBSERVATION FIRST HR G0378 HCPCS 762 RC inpatient 43.4 21.7 IMA of Louisiana Commercial PPO 36.89 percent of total billed charges 21.7 36.89 Inpatient Reimbursement at 85% of Billed Charges OBSERVATION FIRST HR G0378 HCPCS 762 RC outpatient 43.4 34.72 IMA of Louisiana Commercial PPO 36.89 percent of total billed charges 34.72 900 Reimbursement at 85% of billed charges OBSERVATION FIRST HR G0378 HCPCS 762 RC outpatient 43.4 34.72 Aetna Commercial PPO 550 case rate 34.72 900 550 Case Rate Once Per Day AIRWAY NASOPHAR 34 FR 272 RC inpatient 25.96 12.98 BCBS Louisiana PPO 12.98 percent of total billed charges 12.98 22.07 50% of Eligible Charges AIRWAY NASOPHAR 34 FR 272 RC outpatient 25.96 20.77 BCBS Louisiana PPO 20.77 percent of total billed charges 14.28 22.07 80% of billed charge AIRWAY NASOPHAR 34 FR 272 RC outpatient 25.96 20.77 Cigna Commercial PPO 14.28 percent of total billed charges 14.28 22.07 55% of Billed Charges AIRWAY NASOPHAR 34 FR 272 RC inpatient 25.96 12.98 IMA of Louisiana Commercial PPO 22.07 percent of total billed charges 12.98 22.07 Inpatient Reimbursement at 85% of Billed Charges AIRWAY NASOPHAR 34 FR 272 RC outpatient 25.96 20.77 IMA of Louisiana Commercial PPO 22.07 percent of total billed charges 14.28 22.07 Reimbursement at 85% of billed charges AIRWAY NASOPHAR 34 FR 272 RC outpatient 25.96 20.77 Aetna Commercial PPO 14.28 percent of total billed charges 14.28 22.07 55 of billed Charges AIRWAY NASOPHAR 36 FR 272 RC inpatient 35.17 17.59 BCBS Louisiana PPO 17.59 percent of total billed charges 17.59 29.89 50% of Eligible Charges AIRWAY NASOPHAR 36 FR 272 RC outpatient 35.17 28.14 BCBS Louisiana PPO 28.14 percent of total billed charges 19.34 29.89 80% of billed charge AIRWAY NASOPHAR 36 FR 272 RC outpatient 35.17 28.14 Cigna Commercial PPO 19.34 percent of total billed charges 19.34 29.89 55% of Billed Charges AIRWAY NASOPHAR 36 FR 272 RC inpatient 35.17 17.59 IMA of Louisiana Commercial PPO 29.89 percent of total billed charges 17.59 29.89 Inpatient Reimbursement at 85% of Billed Charges AIRWAY NASOPHAR 36 FR 272 RC outpatient 35.17 28.14 IMA of Louisiana Commercial PPO 29.89 percent of total billed charges 19.34 29.89 Reimbursement at 85% of billed charges AIRWAY NASOPHAR 36 FR 272 RC outpatient 35.17 28.14 Aetna Commercial PPO 19.34 percent of total billed charges 19.34 29.89 55 of billed Charges STOCKING XXL KNEE 270 RC inpatient 378.18 189.09 BCBS Louisiana PPO 189.09 percent of total billed charges 189.09 321.45 50% of Eligible Charges STOCKING XXL KNEE 270 RC outpatient 378.18 302.54 BCBS Louisiana PPO 302.54 percent of total billed charges 208 321.45 80% of billed charge STOCKING XXL KNEE 270 RC outpatient 378.18 302.54 Cigna Commercial PPO 208 percent of total billed charges 208 321.45 55% of Billed Charges STOCKING XXL KNEE 270 RC inpatient 378.18 189.09 IMA of Louisiana Commercial PPO 321.45 percent of total billed charges 189.09 321.45 Inpatient Reimbursement at 85% of Billed Charges STOCKING XXL KNEE 270 RC outpatient 378.18 302.54 IMA of Louisiana Commercial PPO 321.45 percent of total billed charges 208 321.45 Reimbursement at 85% of billed charges STOCKING XXL KNEE 270 RC outpatient 378.18 302.54 Aetna Commercial PPO 208 percent of total billed charges 208 321.45 55 of billed Charges SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC inpatient 530.56 265.28 BCBS Louisiana PPO 265.28 percent of total billed charges 265.28 450.98 50% of Eligible Charges SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC outpatient 530.56 424.45 BCBS Louisiana PPO 424.45 percent of total billed charges 291.81 450.98 80% of billed charge SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC outpatient 530.56 424.45 Cigna Commercial PPO 291.81 percent of total billed charges 291.81 450.98 55% of Billed Charges SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC inpatient 530.56 265.28 IMA of Louisiana Commercial PPO 450.98 percent of total billed charges 265.28 450.98 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC outpatient 530.56 424.45 IMA of Louisiana Commercial PPO 450.98 percent of total billed charges 291.81 450.98 Reimbursement at 85% of billed charges SUTURE STRATAFIX/QUILL 3-0 MONO 272 RC outpatient 530.56 424.45 Aetna Commercial PPO 291.81 percent of total billed charges 291.81 450.98 55 of billed Charges ARM CRADLE LAMINECTOMY 270 RC inpatient 20.76 10.38 BCBS Louisiana PPO 10.38 percent of total billed charges 10.38 17.65 50% of Eligible Charges ARM CRADLE LAMINECTOMY 270 RC outpatient 20.76 16.61 BCBS Louisiana PPO 16.61 percent of total billed charges 11.42 17.65 80% of billed charge ARM CRADLE LAMINECTOMY 270 RC outpatient 20.76 16.61 Cigna Commercial PPO 11.42 percent of total billed charges 11.42 17.65 55% of Billed Charges ARM CRADLE LAMINECTOMY 270 RC inpatient 20.76 10.38 IMA of Louisiana Commercial PPO 17.65 percent of total billed charges 10.38 17.65 Inpatient Reimbursement at 85% of Billed Charges ARM CRADLE LAMINECTOMY 270 RC outpatient 20.76 16.61 IMA of Louisiana Commercial PPO 17.65 percent of total billed charges 11.42 17.65 Reimbursement at 85% of billed charges ARM CRADLE LAMINECTOMY 270 RC outpatient 20.76 16.61 Aetna Commercial PPO 11.42 percent of total billed charges 11.42 17.65 55 of billed Charges DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC inpatient 221.38 110.69 BCBS Louisiana PPO 110.69 percent of total billed charges 110.69 188.17 50% of Eligible Charges DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC outpatient 221.38 177.1 BCBS Louisiana PPO 177.1 percent of total billed charges 121.76 188.17 80% of billed charge DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC outpatient 221.38 177.1 Cigna Commercial PPO 121.76 percent of total billed charges 121.76 188.17 55% of Billed Charges DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC inpatient 221.38 110.69 IMA of Louisiana Commercial PPO 188.17 percent of total billed charges 110.69 188.17 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC outpatient 221.38 177.1 IMA of Louisiana Commercial PPO 188.17 percent of total billed charges 121.76 188.17 Reimbursement at 85% of billed charges DRILL BIT 2.5MM QC GOLD 110MM - SYNTHES 272 RC outpatient 221.38 177.1 Aetna Commercial PPO 121.76 percent of total billed charges 121.76 188.17 55 of billed Charges BLADE CARPAL TUNNEL 272 RC inpatient 465.75 232.88 BCBS Louisiana PPO 232.88 percent of total billed charges 232.88 395.89 50% of Eligible Charges BLADE CARPAL TUNNEL 272 RC outpatient 465.75 372.6 BCBS Louisiana PPO 372.6 percent of total billed charges 256.16 395.89 80% of billed charge BLADE CARPAL TUNNEL 272 RC outpatient 465.75 372.6 Cigna Commercial PPO 256.16 percent of total billed charges 256.16 395.89 55% of Billed Charges BLADE CARPAL TUNNEL 272 RC inpatient 465.75 232.88 IMA of Louisiana Commercial PPO 395.89 percent of total billed charges 232.88 395.89 Inpatient Reimbursement at 85% of Billed Charges BLADE CARPAL TUNNEL 272 RC outpatient 465.75 372.6 IMA of Louisiana Commercial PPO 395.89 percent of total billed charges 256.16 395.89 Reimbursement at 85% of billed charges BLADE CARPAL TUNNEL 272 RC outpatient 465.75 372.6 Aetna Commercial PPO 256.16 percent of total billed charges 256.16 395.89 55 of billed Charges SUTURE 4-0 MONOCRYL P3 Y494G 272 RC inpatient 25.84 12.92 BCBS Louisiana PPO 12.92 percent of total billed charges 12.92 21.96 50% of Eligible Charges SUTURE 4-0 MONOCRYL P3 Y494G 272 RC outpatient 25.84 20.67 BCBS Louisiana PPO 20.67 percent of total billed charges 14.21 21.96 80% of billed charge SUTURE 4-0 MONOCRYL P3 Y494G 272 RC outpatient 25.84 20.67 Cigna Commercial PPO 14.21 percent of total billed charges 14.21 21.96 55% of Billed Charges SUTURE 4-0 MONOCRYL P3 Y494G 272 RC inpatient 25.84 12.92 IMA of Louisiana Commercial PPO 21.96 percent of total billed charges 12.92 21.96 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 MONOCRYL P3 Y494G 272 RC outpatient 25.84 20.67 IMA of Louisiana Commercial PPO 21.96 percent of total billed charges 14.21 21.96 Reimbursement at 85% of billed charges SUTURE 4-0 MONOCRYL P3 Y494G 272 RC outpatient 25.84 20.67 Aetna Commercial PPO 14.21 percent of total billed charges 14.21 21.96 55 of billed Charges ACTICOAT DRESSING 4 X 13 - 272 RC inpatient 330.47 165.24 BCBS Louisiana PPO 165.24 percent of total billed charges 165.24 280.9 50% of Eligible Charges ACTICOAT DRESSING 4 X 13 - 272 RC outpatient 330.47 264.38 BCBS Louisiana PPO 264.38 percent of total billed charges 181.76 280.9 80% of billed charge ACTICOAT DRESSING 4 X 13 - 272 RC outpatient 330.47 264.38 Cigna Commercial PPO 181.76 percent of total billed charges 181.76 280.9 55% of Billed Charges ACTICOAT DRESSING 4 X 13 - 272 RC inpatient 330.47 165.24 IMA of Louisiana Commercial PPO 280.9 percent of total billed charges 165.24 280.9 Inpatient Reimbursement at 85% of Billed Charges ACTICOAT DRESSING 4 X 13 - 272 RC outpatient 330.47 264.38 IMA of Louisiana Commercial PPO 280.9 percent of total billed charges 181.76 280.9 Reimbursement at 85% of billed charges ACTICOAT DRESSING 4 X 13 - 272 RC outpatient 330.47 264.38 Aetna Commercial PPO 181.76 percent of total billed charges 181.76 280.9 55 of billed Charges CATHETER FOLEY PUNCH 14FR - GU CART 272 RC inpatient 452.1 226.05 BCBS Louisiana PPO 226.05 percent of total billed charges 226.05 384.29 50% of Eligible Charges CATHETER FOLEY PUNCH 14FR - GU CART 272 RC outpatient 452.1 361.68 BCBS Louisiana PPO 361.68 percent of total billed charges 248.66 384.29 80% of billed charge CATHETER FOLEY PUNCH 14FR - GU CART 272 RC outpatient 452.1 361.68 Cigna Commercial PPO 248.66 percent of total billed charges 248.66 384.29 55% of Billed Charges CATHETER FOLEY PUNCH 14FR - GU CART 272 RC inpatient 452.1 226.05 IMA of Louisiana Commercial PPO 384.29 percent of total billed charges 226.05 384.29 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY PUNCH 14FR - GU CART 272 RC outpatient 452.1 361.68 IMA of Louisiana Commercial PPO 384.29 percent of total billed charges 248.66 384.29 Reimbursement at 85% of billed charges CATHETER FOLEY PUNCH 14FR - GU CART 272 RC outpatient 452.1 361.68 Aetna Commercial PPO 248.66 percent of total billed charges 248.66 384.29 55 of billed Charges PNEUMOTHORAX KIT 272 RC inpatient 502.25 251.13 BCBS Louisiana PPO 251.13 percent of total billed charges 251.13 426.91 50% of Eligible Charges PNEUMOTHORAX KIT 272 RC outpatient 502.25 401.8 BCBS Louisiana PPO 401.8 percent of total billed charges 276.24 426.91 80% of billed charge PNEUMOTHORAX KIT 272 RC outpatient 502.25 401.8 Cigna Commercial PPO 276.24 percent of total billed charges 276.24 426.91 55% of Billed Charges PNEUMOTHORAX KIT 272 RC inpatient 502.25 251.13 IMA of Louisiana Commercial PPO 426.91 percent of total billed charges 251.13 426.91 Inpatient Reimbursement at 85% of Billed Charges PNEUMOTHORAX KIT 272 RC outpatient 502.25 401.8 IMA of Louisiana Commercial PPO 426.91 percent of total billed charges 276.24 426.91 Reimbursement at 85% of billed charges PNEUMOTHORAX KIT 272 RC outpatient 502.25 401.8 Aetna Commercial PPO 276.24 percent of total billed charges 276.24 426.91 55 of billed Charges BUR 4.0MM EGG K-38 272 RC inpatient 62.4 31.2 BCBS Louisiana PPO 31.2 percent of total billed charges 31.2 53.04 50% of Eligible Charges BUR 4.0MM EGG K-38 272 RC outpatient 62.4 49.92 BCBS Louisiana PPO 49.92 percent of total billed charges 34.32 53.04 80% of billed charge BUR 4.0MM EGG K-38 272 RC outpatient 62.4 49.92 Cigna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55% of Billed Charges BUR 4.0MM EGG K-38 272 RC inpatient 62.4 31.2 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 31.2 53.04 Inpatient Reimbursement at 85% of Billed Charges BUR 4.0MM EGG K-38 272 RC outpatient 62.4 49.92 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 34.32 53.04 Reimbursement at 85% of billed charges BUR 4.0MM EGG K-38 272 RC outpatient 62.4 49.92 Aetna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55 of billed Charges CAST PADDING 4 270 RC inpatient 64.84 32.42 BCBS Louisiana PPO 32.42 percent of total billed charges 32.42 55.11 50% of Eligible Charges CAST PADDING 4 270 RC outpatient 64.84 51.87 BCBS Louisiana PPO 51.87 percent of total billed charges 35.66 55.11 80% of billed charge CAST PADDING 4 270 RC outpatient 64.84 51.87 Cigna Commercial PPO 35.66 percent of total billed charges 35.66 55.11 55% of Billed Charges CAST PADDING 4 270 RC inpatient 64.84 32.42 IMA of Louisiana Commercial PPO 55.11 percent of total billed charges 32.42 55.11 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 4 270 RC outpatient 64.84 51.87 IMA of Louisiana Commercial PPO 55.11 percent of total billed charges 35.66 55.11 Reimbursement at 85% of billed charges CAST PADDING 4 270 RC outpatient 64.84 51.87 Aetna Commercial PPO 35.66 percent of total billed charges 35.66 55.11 55 of billed Charges CAST PADDING 4 STERILE 272 RC inpatient 332.33 166.17 BCBS Louisiana PPO 166.17 percent of total billed charges 166.17 282.48 50% of Eligible Charges CAST PADDING 4 STERILE 272 RC outpatient 332.33 265.86 BCBS Louisiana PPO 265.86 percent of total billed charges 182.78 282.48 80% of billed charge CAST PADDING 4 STERILE 272 RC outpatient 332.33 265.86 Cigna Commercial PPO 182.78 percent of total billed charges 182.78 282.48 55% of Billed Charges CAST PADDING 4 STERILE 272 RC inpatient 332.33 166.17 IMA of Louisiana Commercial PPO 282.48 percent of total billed charges 166.17 282.48 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 4 STERILE 272 RC outpatient 332.33 265.86 IMA of Louisiana Commercial PPO 282.48 percent of total billed charges 182.78 282.48 Reimbursement at 85% of billed charges CAST PADDING 4 STERILE 272 RC outpatient 332.33 265.86 Aetna Commercial PPO 182.78 percent of total billed charges 182.78 282.48 55 of billed Charges DEFOGGER 272 RC inpatient 7.32 3.66 BCBS Louisiana PPO 3.66 percent of total billed charges 3.66 6.22 50% of Eligible Charges DEFOGGER 272 RC outpatient 7.32 5.86 BCBS Louisiana PPO 5.86 percent of total billed charges 4.03 6.22 80% of billed charge DEFOGGER 272 RC outpatient 7.32 5.86 Cigna Commercial PPO 4.03 percent of total billed charges 4.03 6.22 55% of Billed Charges DEFOGGER 272 RC inpatient 7.32 3.66 IMA of Louisiana Commercial PPO 6.22 percent of total billed charges 3.66 6.22 Inpatient Reimbursement at 85% of Billed Charges DEFOGGER 272 RC outpatient 7.32 5.86 IMA of Louisiana Commercial PPO 6.22 percent of total billed charges 4.03 6.22 Reimbursement at 85% of billed charges DEFOGGER 272 RC outpatient 7.32 5.86 Aetna Commercial PPO 4.03 percent of total billed charges 4.03 6.22 55 of billed Charges DRAPE BACK TABLE 272 RC inpatient 12.52 6.26 BCBS Louisiana PPO 6.26 percent of total billed charges 6.26 10.64 50% of Eligible Charges DRAPE BACK TABLE 272 RC outpatient 12.52 10.02 BCBS Louisiana PPO 10.02 percent of total billed charges 6.89 10.64 80% of billed charge DRAPE BACK TABLE 272 RC outpatient 12.52 10.02 Cigna Commercial PPO 6.89 percent of total billed charges 6.89 10.64 55% of Billed Charges DRAPE BACK TABLE 272 RC inpatient 12.52 6.26 IMA of Louisiana Commercial PPO 10.64 percent of total billed charges 6.26 10.64 Inpatient Reimbursement at 85% of Billed Charges DRAPE BACK TABLE 272 RC outpatient 12.52 10.02 IMA of Louisiana Commercial PPO 10.64 percent of total billed charges 6.89 10.64 Reimbursement at 85% of billed charges DRAPE BACK TABLE 272 RC outpatient 12.52 10.02 Aetna Commercial PPO 6.89 percent of total billed charges 6.89 10.64 55 of billed Charges DRAPE C-ARM IMAGE BONNETT 272 RC inpatient 11.87 5.94 BCBS Louisiana PPO 5.94 percent of total billed charges 5.94 10.09 50% of Eligible Charges DRAPE C-ARM IMAGE BONNETT 272 RC outpatient 11.87 9.5 BCBS Louisiana PPO 9.5 percent of total billed charges 6.53 10.09 80% of billed charge DRAPE C-ARM IMAGE BONNETT 272 RC outpatient 11.87 9.5 Cigna Commercial PPO 6.53 percent of total billed charges 6.53 10.09 55% of Billed Charges DRAPE C-ARM IMAGE BONNETT 272 RC inpatient 11.87 5.94 IMA of Louisiana Commercial PPO 10.09 percent of total billed charges 5.94 10.09 Inpatient Reimbursement at 85% of Billed Charges DRAPE C-ARM IMAGE BONNETT 272 RC outpatient 11.87 9.5 IMA of Louisiana Commercial PPO 10.09 percent of total billed charges 6.53 10.09 Reimbursement at 85% of billed charges DRAPE C-ARM IMAGE BONNETT 272 RC outpatient 11.87 9.5 Aetna Commercial PPO 6.53 percent of total billed charges 6.53 10.09 55 of billed Charges DRAPE EXTREMITY 272 RC inpatient 27.12 13.56 BCBS Louisiana PPO 13.56 percent of total billed charges 13.56 23.05 50% of Eligible Charges DRAPE EXTREMITY 272 RC outpatient 27.12 21.7 BCBS Louisiana PPO 21.7 percent of total billed charges 14.92 23.05 80% of billed charge DRAPE EXTREMITY 272 RC outpatient 27.12 21.7 Cigna Commercial PPO 14.92 percent of total billed charges 14.92 23.05 55% of Billed Charges DRAPE EXTREMITY 272 RC inpatient 27.12 13.56 IMA of Louisiana Commercial PPO 23.05 percent of total billed charges 13.56 23.05 Inpatient Reimbursement at 85% of Billed Charges DRAPE EXTREMITY 272 RC outpatient 27.12 21.7 IMA of Louisiana Commercial PPO 23.05 percent of total billed charges 14.92 23.05 Reimbursement at 85% of billed charges DRAPE EXTREMITY 272 RC outpatient 27.12 21.7 Aetna Commercial PPO 14.92 percent of total billed charges 14.92 23.05 55 of billed Charges DRAPE TRANSVERSE 272 RC inpatient 424.03 212.02 BCBS Louisiana PPO 212.02 percent of total billed charges 212.02 360.43 50% of Eligible Charges DRAPE TRANSVERSE 272 RC outpatient 424.03 339.22 BCBS Louisiana PPO 339.22 percent of total billed charges 233.22 360.43 80% of billed charge DRAPE TRANSVERSE 272 RC outpatient 424.03 339.22 Cigna Commercial PPO 233.22 percent of total billed charges 233.22 360.43 55% of Billed Charges DRAPE TRANSVERSE 272 RC inpatient 424.03 212.02 IMA of Louisiana Commercial PPO 360.43 percent of total billed charges 212.02 360.43 Inpatient Reimbursement at 85% of Billed Charges DRAPE TRANSVERSE 272 RC outpatient 424.03 339.22 IMA of Louisiana Commercial PPO 360.43 percent of total billed charges 233.22 360.43 Reimbursement at 85% of billed charges DRAPE TRANSVERSE 272 RC outpatient 424.03 339.22 Aetna Commercial PPO 233.22 percent of total billed charges 233.22 360.43 55 of billed Charges ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC inpatient 501.02 250.51 BCBS Louisiana PPO 250.51 percent of total billed charges 250.51 425.87 50% of Eligible Charges ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC outpatient 501.02 400.82 BCBS Louisiana PPO 400.82 percent of total billed charges 275.56 425.87 80% of billed charge ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC outpatient 501.02 400.82 Cigna Commercial PPO 275.56 percent of total billed charges 275.56 425.87 55% of Billed Charges ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC inpatient 501.02 250.51 IMA of Louisiana Commercial PPO 425.87 percent of total billed charges 250.51 425.87 Inpatient Reimbursement at 85% of Billed Charges ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC outpatient 501.02 400.82 IMA of Louisiana Commercial PPO 425.87 percent of total billed charges 275.56 425.87 Reimbursement at 85% of billed charges ELECTROCAUTERY ENDOSCOPIC BOVIE 272 RC outpatient 501.02 400.82 Aetna Commercial PPO 275.56 percent of total billed charges 275.56 425.87 55 of billed Charges ENDO TUBE W/CUFF 7.0 272 RC inpatient 10.81 5.41 BCBS Louisiana PPO 5.41 percent of total billed charges 5.41 9.19 50% of Eligible Charges ENDO TUBE W/CUFF 7.0 272 RC outpatient 10.81 8.65 BCBS Louisiana PPO 8.65 percent of total billed charges 5.95 9.19 80% of billed charge ENDO TUBE W/CUFF 7.0 272 RC outpatient 10.81 8.65 Cigna Commercial PPO 5.95 percent of total billed charges 5.95 9.19 55% of Billed Charges ENDO TUBE W/CUFF 7.0 272 RC inpatient 10.81 5.41 IMA of Louisiana Commercial PPO 9.19 percent of total billed charges 5.41 9.19 Inpatient Reimbursement at 85% of Billed Charges ENDO TUBE W/CUFF 7.0 272 RC outpatient 10.81 8.65 IMA of Louisiana Commercial PPO 9.19 percent of total billed charges 5.95 9.19 Reimbursement at 85% of billed charges ENDO TUBE W/CUFF 7.0 272 RC outpatient 10.81 8.65 Aetna Commercial PPO 5.95 percent of total billed charges 5.95 9.19 55 of billed Charges ENDO TUBE W/CUFF 8.0 272 RC inpatient 11.25 5.63 BCBS Louisiana PPO 5.63 percent of total billed charges 5.63 9.56 50% of Eligible Charges ENDO TUBE W/CUFF 8.0 272 RC outpatient 11.25 9 BCBS Louisiana PPO 9 percent of total billed charges 6.19 9.56 80% of billed charge ENDO TUBE W/CUFF 8.0 272 RC outpatient 11.25 9 Cigna Commercial PPO 6.19 percent of total billed charges 6.19 9.56 55% of Billed Charges ENDO TUBE W/CUFF 8.0 272 RC inpatient 11.25 5.63 IMA of Louisiana Commercial PPO 9.56 percent of total billed charges 5.63 9.56 Inpatient Reimbursement at 85% of Billed Charges ENDO TUBE W/CUFF 8.0 272 RC outpatient 11.25 9 IMA of Louisiana Commercial PPO 9.56 percent of total billed charges 6.19 9.56 Reimbursement at 85% of billed charges ENDO TUBE W/CUFF 8.0 272 RC outpatient 11.25 9 Aetna Commercial PPO 6.19 percent of total billed charges 6.19 9.56 55 of billed Charges GLOVE STERILE 8.0 LTX 272 RC inpatient 4.76 2.38 BCBS Louisiana PPO 2.38 percent of total billed charges 2.38 4.05 50% of Eligible Charges GLOVE STERILE 8.0 LTX 272 RC outpatient 4.76 3.81 BCBS Louisiana PPO 3.81 percent of total billed charges 2.62 4.05 80% of billed charge GLOVE STERILE 8.0 LTX 272 RC outpatient 4.76 3.81 Cigna Commercial PPO 2.62 percent of total billed charges 2.62 4.05 55% of Billed Charges GLOVE STERILE 8.0 LTX 272 RC inpatient 4.76 2.38 IMA of Louisiana Commercial PPO 4.05 percent of total billed charges 2.38 4.05 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 8.0 LTX 272 RC outpatient 4.76 3.81 IMA of Louisiana Commercial PPO 4.05 percent of total billed charges 2.62 4.05 Reimbursement at 85% of billed charges GLOVE STERILE 8.0 LTX 272 RC outpatient 4.76 3.81 Aetna Commercial PPO 2.62 percent of total billed charges 2.62 4.05 55 of billed Charges NEPTUNE MANIFOLD 270 RC inpatient 590 295 BCBS Louisiana PPO 295 percent of total billed charges 295 501.5 50% of Eligible Charges NEPTUNE MANIFOLD 270 RC outpatient 590 472 BCBS Louisiana PPO 472 percent of total billed charges 324.5 501.5 80% of billed charge NEPTUNE MANIFOLD 270 RC outpatient 590 472 Cigna Commercial PPO 324.5 percent of total billed charges 324.5 501.5 55% of Billed Charges NEPTUNE MANIFOLD 270 RC inpatient 590 295 IMA of Louisiana Commercial PPO 501.5 percent of total billed charges 295 501.5 Inpatient Reimbursement at 85% of Billed Charges NEPTUNE MANIFOLD 270 RC outpatient 590 472 IMA of Louisiana Commercial PPO 501.5 percent of total billed charges 324.5 501.5 Reimbursement at 85% of billed charges NEPTUNE MANIFOLD 270 RC outpatient 590 472 Aetna Commercial PPO 324.5 percent of total billed charges 324.5 501.5 55 of billed Charges NEEDLE BLUNT CANNULA 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges NEEDLE BLUNT CANNULA 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge NEEDLE BLUNT CANNULA 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges NEEDLE BLUNT CANNULA 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges NEEDLE BLUNT CANNULA 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges NEEDLE BLUNT CANNULA 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges IV CATH 18G 272 RC inpatient 424.38 212.19 BCBS Louisiana PPO 212.19 percent of total billed charges 212.19 360.72 50% of Eligible Charges IV CATH 18G 272 RC outpatient 424.38 339.5 BCBS Louisiana PPO 339.5 percent of total billed charges 233.41 360.72 80% of billed charge IV CATH 18G 272 RC outpatient 424.38 339.5 Cigna Commercial PPO 233.41 percent of total billed charges 233.41 360.72 55% of Billed Charges IV CATH 18G 272 RC inpatient 424.38 212.19 IMA of Louisiana Commercial PPO 360.72 percent of total billed charges 212.19 360.72 Inpatient Reimbursement at 85% of Billed Charges IV CATH 18G 272 RC outpatient 424.38 339.5 IMA of Louisiana Commercial PPO 360.72 percent of total billed charges 233.41 360.72 Reimbursement at 85% of billed charges IV CATH 18G 272 RC outpatient 424.38 339.5 Aetna Commercial PPO 233.41 percent of total billed charges 233.41 360.72 55 of billed Charges SAW BLADE 2108-152 272 RC inpatient 93.6 46.8 BCBS Louisiana PPO 46.8 percent of total billed charges 46.8 79.56 50% of Eligible Charges SAW BLADE 2108-152 272 RC outpatient 93.6 74.88 BCBS Louisiana PPO 74.88 percent of total billed charges 51.48 79.56 80% of billed charge SAW BLADE 2108-152 272 RC outpatient 93.6 74.88 Cigna Commercial PPO 51.48 percent of total billed charges 51.48 79.56 55% of Billed Charges SAW BLADE 2108-152 272 RC inpatient 93.6 46.8 IMA of Louisiana Commercial PPO 79.56 percent of total billed charges 46.8 79.56 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-152 272 RC outpatient 93.6 74.88 IMA of Louisiana Commercial PPO 79.56 percent of total billed charges 51.48 79.56 Reimbursement at 85% of billed charges SAW BLADE 2108-152 272 RC outpatient 93.6 74.88 Aetna Commercial PPO 51.48 percent of total billed charges 51.48 79.56 55 of billed Charges KERLIX 4 STERILE 272 RC inpatient 4.07 2.04 BCBS Louisiana PPO 2.04 percent of total billed charges 2.04 3.46 50% of Eligible Charges KERLIX 4 STERILE 272 RC outpatient 4.07 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 2.24 3.46 80% of billed charge KERLIX 4 STERILE 272 RC outpatient 4.07 3.26 Cigna Commercial PPO 2.24 percent of total billed charges 2.24 3.46 55% of Billed Charges KERLIX 4 STERILE 272 RC inpatient 4.07 2.04 IMA of Louisiana Commercial PPO 3.46 percent of total billed charges 2.04 3.46 Inpatient Reimbursement at 85% of Billed Charges KERLIX 4 STERILE 272 RC outpatient 4.07 3.26 IMA of Louisiana Commercial PPO 3.46 percent of total billed charges 2.24 3.46 Reimbursement at 85% of billed charges KERLIX 4 STERILE 272 RC outpatient 4.07 3.26 Aetna Commercial PPO 2.24 percent of total billed charges 2.24 3.46 55 of billed Charges CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC inpatient 562.5 281.25 BCBS Louisiana PPO 281.25 percent of total billed charges 281.25 478.13 50% of Eligible Charges CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC outpatient 562.5 450 BCBS Louisiana PPO 450 percent of total billed charges 309.38 478.13 80% of billed charge CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC outpatient 562.5 450 Cigna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55% of Billed Charges CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC inpatient 562.5 281.25 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 281.25 478.13 Inpatient Reimbursement at 85% of Billed Charges CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC outpatient 562.5 450 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 309.38 478.13 Reimbursement at 85% of billed charges CANNULA - CLEAR TRAC 8.5X72MM - S&N ENDO 272 RC outpatient 562.5 450 Aetna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55 of billed Charges NEEDLE CHIBA 20G X 15CM 272 RC inpatient 37.52 18.76 BCBS Louisiana PPO 18.76 percent of total billed charges 18.76 31.89 50% of Eligible Charges NEEDLE CHIBA 20G X 15CM 272 RC outpatient 37.52 30.02 BCBS Louisiana PPO 30.02 percent of total billed charges 20.64 31.89 80% of billed charge NEEDLE CHIBA 20G X 15CM 272 RC outpatient 37.52 30.02 Cigna Commercial PPO 20.64 percent of total billed charges 20.64 31.89 55% of Billed Charges NEEDLE CHIBA 20G X 15CM 272 RC inpatient 37.52 18.76 IMA of Louisiana Commercial PPO 31.89 percent of total billed charges 18.76 31.89 Inpatient Reimbursement at 85% of Billed Charges NEEDLE CHIBA 20G X 15CM 272 RC outpatient 37.52 30.02 IMA of Louisiana Commercial PPO 31.89 percent of total billed charges 20.64 31.89 Reimbursement at 85% of billed charges NEEDLE CHIBA 20G X 15CM 272 RC outpatient 37.52 30.02 Aetna Commercial PPO 20.64 percent of total billed charges 20.64 31.89 55 of billed Charges PIN BALL .045 270 RC inpatient 161 80.5 BCBS Louisiana PPO 80.5 percent of total billed charges 80.5 136.85 50% of Eligible Charges PIN BALL .045 270 RC outpatient 161 128.8 BCBS Louisiana PPO 128.8 percent of total billed charges 88.55 136.85 80% of billed charge PIN BALL .045 270 RC outpatient 161 128.8 Cigna Commercial PPO 88.55 percent of total billed charges 88.55 136.85 55% of Billed Charges PIN BALL .045 270 RC inpatient 161 80.5 IMA of Louisiana Commercial PPO 136.85 percent of total billed charges 80.5 136.85 Inpatient Reimbursement at 85% of Billed Charges PIN BALL .045 270 RC outpatient 161 128.8 IMA of Louisiana Commercial PPO 136.85 percent of total billed charges 88.55 136.85 Reimbursement at 85% of billed charges PIN BALL .045 270 RC outpatient 161 128.8 Aetna Commercial PPO 88.55 percent of total billed charges 88.55 136.85 55 of billed Charges PLASTER SPLINT 3 X 15 FAST 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges PLASTER SPLINT 3 X 15 FAST 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge PLASTER SPLINT 3 X 15 FAST 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges PLASTER SPLINT 3 X 15 FAST 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges PLASTER SPLINT 3 X 15 FAST 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges PLASTER SPLINT 3 X 15 FAST 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 64.75 148.75 80% of billed charge PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC outpatient 175 140 Cigna Commercial PPO 101.5 percent of total billed charges 64.75 148.75 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 64.75 148.75 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR W/ 7 HOLE 85MM - SYN C1713 HCPCS 278 RC outpatient 175 140 Aetna Commercial PPO 64.75 percent of total billed charges 64.75 148.75 37% Of Billed Charges 2000 PREP KIT (SKIN WET) 272 RC inpatient 515.45 257.73 BCBS Louisiana PPO 257.73 percent of total billed charges 257.73 438.13 50% of Eligible Charges PREP KIT (SKIN WET) 272 RC outpatient 515.45 412.36 BCBS Louisiana PPO 412.36 percent of total billed charges 283.5 438.13 80% of billed charge PREP KIT (SKIN WET) 272 RC outpatient 515.45 412.36 Cigna Commercial PPO 283.5 percent of total billed charges 283.5 438.13 55% of Billed Charges PREP KIT (SKIN WET) 272 RC inpatient 515.45 257.73 IMA of Louisiana Commercial PPO 438.13 percent of total billed charges 257.73 438.13 Inpatient Reimbursement at 85% of Billed Charges PREP KIT (SKIN WET) 272 RC outpatient 515.45 412.36 IMA of Louisiana Commercial PPO 438.13 percent of total billed charges 283.5 438.13 Reimbursement at 85% of billed charges PREP KIT (SKIN WET) 272 RC outpatient 515.45 412.36 Aetna Commercial PPO 283.5 percent of total billed charges 283.5 438.13 55 of billed Charges SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 113.82 56.91 BCBS Louisiana PPO 56.91 percent of total billed charges 56.91 96.75 50% of Eligible Charges SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 BCBS Louisiana PPO 91.06 percent of total billed charges 42.11 96.75 80% of billed charge SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 Cigna Commercial PPO 66.02 percent of total billed charges 42.11 96.75 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 113.82 56.91 IMA of Louisiana Commercial PPO 96.75 percent of total billed charges 56.91 96.75 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 IMA of Louisiana Commercial PPO 96.75 percent of total billed charges 42.11 96.75 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 10MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 Aetna Commercial PPO 42.11 percent of total billed charges 42.11 96.75 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC inpatient 280 140 BCBS Louisiana PPO 140 percent of total billed charges 140 238 50% of Eligible Charges BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC outpatient 280 224 BCBS Louisiana PPO 224 percent of total billed charges 154 238 80% of billed charge BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC outpatient 280 224 Cigna Commercial PPO 154 percent of total billed charges 154 238 55% of Billed Charges BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC inpatient 280 140 IMA of Louisiana Commercial PPO 238 percent of total billed charges 140 238 Inpatient Reimbursement at 85% of Billed Charges BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC outpatient 280 224 IMA of Louisiana Commercial PPO 238 percent of total billed charges 154 238 Reimbursement at 85% of billed charges BUR 5.0MM BARREL 5130-17-50 STRYKER 272 RC outpatient 280 224 Aetna Commercial PPO 154 percent of total billed charges 154 238 55 of billed Charges DISTRACTION PIN 14MM 272 RC inpatient 500 250 BCBS Louisiana PPO 250 percent of total billed charges 250 425 50% of Eligible Charges DISTRACTION PIN 14MM 272 RC outpatient 500 400 BCBS Louisiana PPO 400 percent of total billed charges 275 425 80% of billed charge DISTRACTION PIN 14MM 272 RC outpatient 500 400 Cigna Commercial PPO 275 percent of total billed charges 275 425 55% of Billed Charges DISTRACTION PIN 14MM 272 RC inpatient 500 250 IMA of Louisiana Commercial PPO 425 percent of total billed charges 250 425 Inpatient Reimbursement at 85% of Billed Charges DISTRACTION PIN 14MM 272 RC outpatient 500 400 IMA of Louisiana Commercial PPO 425 percent of total billed charges 275 425 Reimbursement at 85% of billed charges DISTRACTION PIN 14MM 272 RC outpatient 500 400 Aetna Commercial PPO 275 percent of total billed charges 275 425 55 of billed Charges CERVICAL COLLAR SM 270 RC inpatient 15.76 7.88 BCBS Louisiana PPO 7.88 percent of total billed charges 7.88 13.4 50% of Eligible Charges CERVICAL COLLAR SM 270 RC outpatient 15.76 12.61 BCBS Louisiana PPO 12.61 percent of total billed charges 8.67 13.4 80% of billed charge CERVICAL COLLAR SM 270 RC outpatient 15.76 12.61 Cigna Commercial PPO 8.67 percent of total billed charges 8.67 13.4 55% of Billed Charges CERVICAL COLLAR SM 270 RC inpatient 15.76 7.88 IMA of Louisiana Commercial PPO 13.4 percent of total billed charges 7.88 13.4 Inpatient Reimbursement at 85% of Billed Charges CERVICAL COLLAR SM 270 RC outpatient 15.76 12.61 IMA of Louisiana Commercial PPO 13.4 percent of total billed charges 8.67 13.4 Reimbursement at 85% of billed charges CERVICAL COLLAR SM 270 RC outpatient 15.76 12.61 Aetna Commercial PPO 8.67 percent of total billed charges 8.67 13.4 55 of billed Charges PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC inpatient 1375 687.5 BCBS Louisiana PPO 687.5 percent of total billed charges 687.5 1168.75 50% of Eligible Charges PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC outpatient 1375 1100 BCBS Louisiana PPO 1100 percent of total billed charges 756.25 1168.75 80% of billed charge PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC outpatient 1375 1100 Cigna Commercial PPO 756.25 percent of total billed charges 756.25 1168.75 55% of Billed Charges PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC inpatient 1375 687.5 IMA of Louisiana Commercial PPO 1168.75 percent of total billed charges 687.5 1168.75 Inpatient Reimbursement at 85% of Billed Charges PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC outpatient 1375 1100 IMA of Louisiana Commercial PPO 1168.75 percent of total billed charges 756.25 1168.75 Reimbursement at 85% of billed charges PAIN PUMP DIAL A ML / 6ML ON-Q 272 RC outpatient 1375 1100 Aetna Commercial PPO 756.25 percent of total billed charges 756.25 1168.75 55 of billed Charges SKIN SCRIB MARKER 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges SKIN SCRIB MARKER 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge SKIN SCRIB MARKER 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges SKIN SCRIB MARKER 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges SKIN SCRIB MARKER 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges SKIN SCRIB MARKER 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges BANDAGE COBAN 2 270 RC inpatient 6.57 3.29 BCBS Louisiana PPO 3.29 percent of total billed charges 3.29 5.58 50% of Eligible Charges BANDAGE COBAN 2 270 RC outpatient 6.57 5.26 BCBS Louisiana PPO 5.26 percent of total billed charges 3.61 5.58 80% of billed charge BANDAGE COBAN 2 270 RC outpatient 6.57 5.26 Cigna Commercial PPO 3.61 percent of total billed charges 3.61 5.58 55% of Billed Charges BANDAGE COBAN 2 270 RC inpatient 6.57 3.29 IMA of Louisiana Commercial PPO 5.58 percent of total billed charges 3.29 5.58 Inpatient Reimbursement at 85% of Billed Charges BANDAGE COBAN 2 270 RC outpatient 6.57 5.26 IMA of Louisiana Commercial PPO 5.58 percent of total billed charges 3.61 5.58 Reimbursement at 85% of billed charges BANDAGE COBAN 2 270 RC outpatient 6.57 5.26 Aetna Commercial PPO 3.61 percent of total billed charges 3.61 5.58 55 of billed Charges SUTURE 1 ETHIBOND CT-1 X425H 272 RC inpatient 7.08 3.54 BCBS Louisiana PPO 3.54 percent of total billed charges 3.54 6.02 50% of Eligible Charges SUTURE 1 ETHIBOND CT-1 X425H 272 RC outpatient 7.08 5.66 BCBS Louisiana PPO 5.66 percent of total billed charges 3.89 6.02 80% of billed charge SUTURE 1 ETHIBOND CT-1 X425H 272 RC outpatient 7.08 5.66 Cigna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55% of Billed Charges SUTURE 1 ETHIBOND CT-1 X425H 272 RC inpatient 7.08 3.54 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.54 6.02 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 ETHIBOND CT-1 X425H 272 RC outpatient 7.08 5.66 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.89 6.02 Reimbursement at 85% of billed charges SUTURE 1 ETHIBOND CT-1 X425H 272 RC outpatient 7.08 5.66 Aetna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55 of billed Charges STOCKINETTE IMP. STERILE LG 54 272 RC inpatient 652.4 326.2 BCBS Louisiana PPO 326.2 percent of total billed charges 326.2 554.54 50% of Eligible Charges STOCKINETTE IMP. STERILE LG 54 272 RC outpatient 652.4 521.92 BCBS Louisiana PPO 521.92 percent of total billed charges 358.82 554.54 80% of billed charge STOCKINETTE IMP. STERILE LG 54 272 RC outpatient 652.4 521.92 Cigna Commercial PPO 358.82 percent of total billed charges 358.82 554.54 55% of Billed Charges STOCKINETTE IMP. STERILE LG 54 272 RC inpatient 652.4 326.2 IMA of Louisiana Commercial PPO 554.54 percent of total billed charges 326.2 554.54 Inpatient Reimbursement at 85% of Billed Charges STOCKINETTE IMP. STERILE LG 54 272 RC outpatient 652.4 521.92 IMA of Louisiana Commercial PPO 554.54 percent of total billed charges 358.82 554.54 Reimbursement at 85% of billed charges STOCKINETTE IMP. STERILE LG 54 272 RC outpatient 652.4 521.92 Aetna Commercial PPO 358.82 percent of total billed charges 358.82 554.54 55 of billed Charges STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC inpatient 22.81 11.41 BCBS Louisiana PPO 11.41 percent of total billed charges 11.41 19.39 50% of Eligible Charges STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC outpatient 22.81 18.25 BCBS Louisiana PPO 18.25 percent of total billed charges 12.55 19.39 80% of billed charge STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC outpatient 22.81 18.25 Cigna Commercial PPO 12.55 percent of total billed charges 12.55 19.39 55% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC inpatient 22.81 11.41 IMA of Louisiana Commercial PPO 19.39 percent of total billed charges 11.41 19.39 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC outpatient 22.81 18.25 IMA of Louisiana Commercial PPO 19.39 percent of total billed charges 12.55 19.39 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM LNG THIGH LG 270 RC outpatient 22.81 18.25 Aetna Commercial PPO 12.55 percent of total billed charges 12.55 19.39 55 of billed Charges STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC inpatient 25.31 12.66 BCBS Louisiana PPO 12.66 percent of total billed charges 12.66 21.51 50% of Eligible Charges STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC outpatient 25.31 20.25 BCBS Louisiana PPO 20.25 percent of total billed charges 13.92 21.51 80% of billed charge STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC outpatient 25.31 20.25 Cigna Commercial PPO 13.92 percent of total billed charges 13.92 21.51 55% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC inpatient 25.31 12.66 IMA of Louisiana Commercial PPO 21.51 percent of total billed charges 12.66 21.51 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC outpatient 25.31 20.25 IMA of Louisiana Commercial PPO 21.51 percent of total billed charges 13.92 21.51 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM LNG THIGH XL 270 RC outpatient 25.31 20.25 Aetna Commercial PPO 13.92 percent of total billed charges 13.92 21.51 55 of billed Charges GLOVE BIOGEL SZ 6 272 RC inpatient 4.2 2.1 BCBS Louisiana PPO 2.1 percent of total billed charges 2.1 3.57 50% of Eligible Charges GLOVE BIOGEL SZ 6 272 RC outpatient 4.2 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 2.31 3.57 80% of billed charge GLOVE BIOGEL SZ 6 272 RC outpatient 4.2 3.36 Cigna Commercial PPO 2.31 percent of total billed charges 2.31 3.57 55% of Billed Charges GLOVE BIOGEL SZ 6 272 RC inpatient 4.2 2.1 IMA of Louisiana Commercial PPO 3.57 percent of total billed charges 2.1 3.57 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 6 272 RC outpatient 4.2 3.36 IMA of Louisiana Commercial PPO 3.57 percent of total billed charges 2.31 3.57 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 6 272 RC outpatient 4.2 3.36 Aetna Commercial PPO 2.31 percent of total billed charges 2.31 3.57 55 of billed Charges SUTURE 6-0 CHROMIC GUT 1731G 272 RC inpatient 521.85 260.93 BCBS Louisiana PPO 260.93 percent of total billed charges 260.93 443.57 50% of Eligible Charges SUTURE 6-0 CHROMIC GUT 1731G 272 RC outpatient 521.85 417.48 BCBS Louisiana PPO 417.48 percent of total billed charges 287.02 443.57 80% of billed charge SUTURE 6-0 CHROMIC GUT 1731G 272 RC outpatient 521.85 417.48 Cigna Commercial PPO 287.02 percent of total billed charges 287.02 443.57 55% of Billed Charges SUTURE 6-0 CHROMIC GUT 1731G 272 RC inpatient 521.85 260.93 IMA of Louisiana Commercial PPO 443.57 percent of total billed charges 260.93 443.57 Inpatient Reimbursement at 85% of Billed Charges SUTURE 6-0 CHROMIC GUT 1731G 272 RC outpatient 521.85 417.48 IMA of Louisiana Commercial PPO 443.57 percent of total billed charges 287.02 443.57 Reimbursement at 85% of billed charges SUTURE 6-0 CHROMIC GUT 1731G 272 RC outpatient 521.85 417.48 Aetna Commercial PPO 287.02 percent of total billed charges 287.02 443.57 55 of billed Charges SUTURE 1 VICRYL CT-2 J335H 272 RC inpatient 6.64 3.32 BCBS Louisiana PPO 3.32 percent of total billed charges 3.32 5.64 50% of Eligible Charges SUTURE 1 VICRYL CT-2 J335H 272 RC outpatient 6.64 5.31 BCBS Louisiana PPO 5.31 percent of total billed charges 3.65 5.64 80% of billed charge SUTURE 1 VICRYL CT-2 J335H 272 RC outpatient 6.64 5.31 Cigna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55% of Billed Charges SUTURE 1 VICRYL CT-2 J335H 272 RC inpatient 6.64 3.32 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.32 5.64 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 VICRYL CT-2 J335H 272 RC outpatient 6.64 5.31 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.65 5.64 Reimbursement at 85% of billed charges SUTURE 1 VICRYL CT-2 J335H 272 RC outpatient 6.64 5.31 Aetna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55 of billed Charges PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC inpatient 28.32 14.16 BCBS Louisiana PPO 14.16 percent of total billed charges 14.16 24.07 50% of Eligible Charges PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC outpatient 28.32 22.66 BCBS Louisiana PPO 22.66 percent of total billed charges 15.58 24.07 80% of billed charge PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC outpatient 28.32 22.66 Cigna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55% of Billed Charges PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC inpatient 28.32 14.16 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 14.16 24.07 Inpatient Reimbursement at 85% of Billed Charges PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC outpatient 28.32 22.66 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 15.58 24.07 Reimbursement at 85% of billed charges PROTECTIVE SLEEVE FOR TOURNIQUETS 272 RC outpatient 28.32 22.66 Aetna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55 of billed Charges SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC inpatient 24.6 12.3 BCBS Louisiana PPO 12.3 percent of total billed charges 12.3 20.91 50% of Eligible Charges SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC outpatient 24.6 19.68 BCBS Louisiana PPO 19.68 percent of total billed charges 13.53 20.91 80% of billed charge SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC outpatient 24.6 19.68 Cigna Commercial PPO 13.53 percent of total billed charges 13.53 20.91 55% of Billed Charges SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC inpatient 24.6 12.3 IMA of Louisiana Commercial PPO 20.91 percent of total billed charges 12.3 20.91 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC outpatient 24.6 19.68 IMA of Louisiana Commercial PPO 20.91 percent of total billed charges 13.53 20.91 Reimbursement at 85% of billed charges SUTURE 3-0 MONOCRYL PS-2 Y427H 272 RC outpatient 24.6 19.68 Aetna Commercial PPO 13.53 percent of total billed charges 13.53 20.91 55 of billed Charges SUTURE 3-0 VICRYL PS-2 J497H 272 RC inpatient 16.72 8.36 BCBS Louisiana PPO 8.36 percent of total billed charges 8.36 14.21 50% of Eligible Charges SUTURE 3-0 VICRYL PS-2 J497H 272 RC outpatient 16.72 13.38 BCBS Louisiana PPO 13.38 percent of total billed charges 9.2 14.21 80% of billed charge SUTURE 3-0 VICRYL PS-2 J497H 272 RC outpatient 16.72 13.38 Cigna Commercial PPO 9.2 percent of total billed charges 9.2 14.21 55% of Billed Charges SUTURE 3-0 VICRYL PS-2 J497H 272 RC inpatient 16.72 8.36 IMA of Louisiana Commercial PPO 14.21 percent of total billed charges 8.36 14.21 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 VICRYL PS-2 J497H 272 RC outpatient 16.72 13.38 IMA of Louisiana Commercial PPO 14.21 percent of total billed charges 9.2 14.21 Reimbursement at 85% of billed charges SUTURE 3-0 VICRYL PS-2 J497H 272 RC outpatient 16.72 13.38 Aetna Commercial PPO 9.2 percent of total billed charges 9.2 14.21 55 of billed Charges SUTURE 4-0ETHIL PS-2 1667H 272 RC inpatient 16.84 8.42 BCBS Louisiana PPO 8.42 percent of total billed charges 8.42 14.31 50% of Eligible Charges SUTURE 4-0ETHIL PS-2 1667H 272 RC outpatient 16.84 13.47 BCBS Louisiana PPO 13.47 percent of total billed charges 9.26 14.31 80% of billed charge SUTURE 4-0ETHIL PS-2 1667H 272 RC outpatient 16.84 13.47 Cigna Commercial PPO 9.26 percent of total billed charges 9.26 14.31 55% of Billed Charges SUTURE 4-0ETHIL PS-2 1667H 272 RC inpatient 16.84 8.42 IMA of Louisiana Commercial PPO 14.31 percent of total billed charges 8.42 14.31 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0ETHIL PS-2 1667H 272 RC outpatient 16.84 13.47 IMA of Louisiana Commercial PPO 14.31 percent of total billed charges 9.26 14.31 Reimbursement at 85% of billed charges SUTURE 4-0ETHIL PS-2 1667H 272 RC outpatient 16.84 13.47 Aetna Commercial PPO 9.26 percent of total billed charges 9.26 14.31 55 of billed Charges STOCKING KNEE - MED LONG 270 RC inpatient 125.13 62.57 BCBS Louisiana PPO 62.57 percent of total billed charges 62.57 106.36 50% of Eligible Charges STOCKING KNEE - MED LONG 270 RC outpatient 125.13 100.1 BCBS Louisiana PPO 100.1 percent of total billed charges 68.82 106.36 80% of billed charge STOCKING KNEE - MED LONG 270 RC outpatient 125.13 100.1 Cigna Commercial PPO 68.82 percent of total billed charges 68.82 106.36 55% of Billed Charges STOCKING KNEE - MED LONG 270 RC inpatient 125.13 62.57 IMA of Louisiana Commercial PPO 106.36 percent of total billed charges 62.57 106.36 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - MED LONG 270 RC outpatient 125.13 100.1 IMA of Louisiana Commercial PPO 106.36 percent of total billed charges 68.82 106.36 Reimbursement at 85% of billed charges STOCKING KNEE - MED LONG 270 RC outpatient 125.13 100.1 Aetna Commercial PPO 68.82 percent of total billed charges 68.82 106.36 55 of billed Charges SUTURE 5-0 VICRYL PS-2 J495H 272 RC inpatient 382.88 191.44 BCBS Louisiana PPO 191.44 percent of total billed charges 191.44 325.45 50% of Eligible Charges SUTURE 5-0 VICRYL PS-2 J495H 272 RC outpatient 382.88 306.3 BCBS Louisiana PPO 306.3 percent of total billed charges 210.58 325.45 80% of billed charge SUTURE 5-0 VICRYL PS-2 J495H 272 RC outpatient 382.88 306.3 Cigna Commercial PPO 210.58 percent of total billed charges 210.58 325.45 55% of Billed Charges SUTURE 5-0 VICRYL PS-2 J495H 272 RC inpatient 382.88 191.44 IMA of Louisiana Commercial PPO 325.45 percent of total billed charges 191.44 325.45 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 VICRYL PS-2 J495H 272 RC outpatient 382.88 306.3 IMA of Louisiana Commercial PPO 325.45 percent of total billed charges 210.58 325.45 Reimbursement at 85% of billed charges SUTURE 5-0 VICRYL PS-2 J495H 272 RC outpatient 382.88 306.3 Aetna Commercial PPO 210.58 percent of total billed charges 210.58 325.45 55 of billed Charges SUTURE 9-0 ETHILON PS-2 272 RC inpatient 471.36 235.68 BCBS Louisiana PPO 235.68 percent of total billed charges 235.68 400.66 50% of Eligible Charges SUTURE 9-0 ETHILON PS-2 272 RC outpatient 471.36 377.09 BCBS Louisiana PPO 377.09 percent of total billed charges 259.25 400.66 80% of billed charge SUTURE 9-0 ETHILON PS-2 272 RC outpatient 471.36 377.09 Cigna Commercial PPO 259.25 percent of total billed charges 259.25 400.66 55% of Billed Charges SUTURE 9-0 ETHILON PS-2 272 RC inpatient 471.36 235.68 IMA of Louisiana Commercial PPO 400.66 percent of total billed charges 235.68 400.66 Inpatient Reimbursement at 85% of Billed Charges SUTURE 9-0 ETHILON PS-2 272 RC outpatient 471.36 377.09 IMA of Louisiana Commercial PPO 400.66 percent of total billed charges 259.25 400.66 Reimbursement at 85% of billed charges SUTURE 9-0 ETHILON PS-2 272 RC outpatient 471.36 377.09 Aetna Commercial PPO 259.25 percent of total billed charges 259.25 400.66 55 of billed Charges SUTURE FIBERWIRE #2 AR-7202 272 RC inpatient 552 276 BCBS Louisiana PPO 276 percent of total billed charges 276 469.2 50% of Eligible Charges SUTURE FIBERWIRE #2 AR-7202 272 RC outpatient 552 441.6 BCBS Louisiana PPO 441.6 percent of total billed charges 303.6 469.2 80% of billed charge SUTURE FIBERWIRE #2 AR-7202 272 RC outpatient 552 441.6 Cigna Commercial PPO 303.6 percent of total billed charges 303.6 469.2 55% of Billed Charges SUTURE FIBERWIRE #2 AR-7202 272 RC inpatient 552 276 IMA of Louisiana Commercial PPO 469.2 percent of total billed charges 276 469.2 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERWIRE #2 AR-7202 272 RC outpatient 552 441.6 IMA of Louisiana Commercial PPO 469.2 percent of total billed charges 303.6 469.2 Reimbursement at 85% of billed charges SUTURE FIBERWIRE #2 AR-7202 272 RC outpatient 552 441.6 Aetna Commercial PPO 303.6 percent of total billed charges 303.6 469.2 55 of billed Charges SYRINGE 20CC FINGER CONTROL 272 RC inpatient 324.63 162.32 BCBS Louisiana PPO 162.32 percent of total billed charges 162.32 275.94 50% of Eligible Charges SYRINGE 20CC FINGER CONTROL 272 RC outpatient 324.63 259.7 BCBS Louisiana PPO 259.7 percent of total billed charges 178.55 275.94 80% of billed charge SYRINGE 20CC FINGER CONTROL 272 RC outpatient 324.63 259.7 Cigna Commercial PPO 178.55 percent of total billed charges 178.55 275.94 55% of Billed Charges SYRINGE 20CC FINGER CONTROL 272 RC inpatient 324.63 162.32 IMA of Louisiana Commercial PPO 275.94 percent of total billed charges 162.32 275.94 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 20CC FINGER CONTROL 272 RC outpatient 324.63 259.7 IMA of Louisiana Commercial PPO 275.94 percent of total billed charges 178.55 275.94 Reimbursement at 85% of billed charges SYRINGE 20CC FINGER CONTROL 272 RC outpatient 324.63 259.7 Aetna Commercial PPO 178.55 percent of total billed charges 178.55 275.94 55 of billed Charges MEPILEX POST-OP DRESSING 4X12 272 RC inpatient 128.8 64.4 BCBS Louisiana PPO 64.4 percent of total billed charges 64.4 109.48 50% of Eligible Charges MEPILEX POST-OP DRESSING 4X12 272 RC outpatient 128.8 103.04 BCBS Louisiana PPO 103.04 percent of total billed charges 70.84 109.48 80% of billed charge MEPILEX POST-OP DRESSING 4X12 272 RC outpatient 128.8 103.04 Cigna Commercial PPO 70.84 percent of total billed charges 70.84 109.48 55% of Billed Charges MEPILEX POST-OP DRESSING 4X12 272 RC inpatient 128.8 64.4 IMA of Louisiana Commercial PPO 109.48 percent of total billed charges 64.4 109.48 Inpatient Reimbursement at 85% of Billed Charges MEPILEX POST-OP DRESSING 4X12 272 RC outpatient 128.8 103.04 IMA of Louisiana Commercial PPO 109.48 percent of total billed charges 70.84 109.48 Reimbursement at 85% of billed charges MEPILEX POST-OP DRESSING 4X12 272 RC outpatient 128.8 103.04 Aetna Commercial PPO 70.84 percent of total billed charges 70.84 109.48 55 of billed Charges TAPE DURAPORE SILK 2 270 RC inpatient 36.08 18.04 BCBS Louisiana PPO 18.04 percent of total billed charges 18.04 30.67 50% of Eligible Charges TAPE DURAPORE SILK 2 270 RC outpatient 36.08 28.86 BCBS Louisiana PPO 28.86 percent of total billed charges 19.84 30.67 80% of billed charge TAPE DURAPORE SILK 2 270 RC outpatient 36.08 28.86 Cigna Commercial PPO 19.84 percent of total billed charges 19.84 30.67 55% of Billed Charges TAPE DURAPORE SILK 2 270 RC inpatient 36.08 18.04 IMA of Louisiana Commercial PPO 30.67 percent of total billed charges 18.04 30.67 Inpatient Reimbursement at 85% of Billed Charges TAPE DURAPORE SILK 2 270 RC outpatient 36.08 28.86 IMA of Louisiana Commercial PPO 30.67 percent of total billed charges 19.84 30.67 Reimbursement at 85% of billed charges TAPE DURAPORE SILK 2 270 RC outpatient 36.08 28.86 Aetna Commercial PPO 19.84 percent of total billed charges 19.84 30.67 55 of billed Charges TAPE MICROPORE PAPER 1 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges TAPE MICROPORE PAPER 1 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge TAPE MICROPORE PAPER 1 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges TAPE MICROPORE PAPER 1 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges TAPE MICROPORE PAPER 1 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges TAPE MICROPORE PAPER 1 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges TEGADERM MEDIUM 4 X 4.5 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges TEGADERM MEDIUM 4 X 4.5 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge TEGADERM MEDIUM 4 X 4.5 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges TEGADERM MEDIUM 4 X 4.5 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges TEGADERM MEDIUM 4 X 4.5 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges TEGADERM MEDIUM 4 X 4.5 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges TINCTURE BENZOIN 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges TINCTURE BENZOIN 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge TINCTURE BENZOIN 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges TINCTURE BENZOIN 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges TINCTURE BENZOIN 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges TINCTURE BENZOIN 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges TRISTAR 50 272 RC inpatient 400 200 BCBS Louisiana PPO 200 percent of total billed charges 200 340 50% of Eligible Charges TRISTAR 50 272 RC outpatient 400 320 BCBS Louisiana PPO 320 percent of total billed charges 220 340 80% of billed charge TRISTAR 50 272 RC outpatient 400 320 Cigna Commercial PPO 220 percent of total billed charges 220 340 55% of Billed Charges TRISTAR 50 272 RC inpatient 400 200 IMA of Louisiana Commercial PPO 340 percent of total billed charges 200 340 Inpatient Reimbursement at 85% of Billed Charges TRISTAR 50 272 RC outpatient 400 320 IMA of Louisiana Commercial PPO 340 percent of total billed charges 220 340 Reimbursement at 85% of billed charges TRISTAR 50 272 RC outpatient 400 320 Aetna Commercial PPO 220 percent of total billed charges 220 340 55 of billed Charges NEEDLE TUOHY 18G X 6 272 RC inpatient 727.46 363.73 BCBS Louisiana PPO 363.73 percent of total billed charges 363.73 618.34 50% of Eligible Charges NEEDLE TUOHY 18G X 6 272 RC outpatient 727.46 581.97 BCBS Louisiana PPO 581.97 percent of total billed charges 400.1 618.34 80% of billed charge NEEDLE TUOHY 18G X 6 272 RC outpatient 727.46 581.97 Cigna Commercial PPO 400.1 percent of total billed charges 400.1 618.34 55% of Billed Charges NEEDLE TUOHY 18G X 6 272 RC inpatient 727.46 363.73 IMA of Louisiana Commercial PPO 618.34 percent of total billed charges 363.73 618.34 Inpatient Reimbursement at 85% of Billed Charges NEEDLE TUOHY 18G X 6 272 RC outpatient 727.46 581.97 IMA of Louisiana Commercial PPO 618.34 percent of total billed charges 400.1 618.34 Reimbursement at 85% of billed charges NEEDLE TUOHY 18G X 6 272 RC outpatient 727.46 581.97 Aetna Commercial PPO 400.1 percent of total billed charges 400.1 618.34 55 of billed Charges GRACILIS TENDON GRAFT C1762 HCPCS 278 RC inpatient 1581.25 790.63 BCBS Louisiana PPO 790.63 percent of total billed charges 790.63 1344.06 50% of Eligible Charges GRACILIS TENDON GRAFT C1762 HCPCS 278 RC outpatient 1581.25 1265 BCBS Louisiana PPO 1265 percent of total billed charges 585.06 1344.06 80% of billed charge GRACILIS TENDON GRAFT C1762 HCPCS 278 RC outpatient 1581.25 1265 Cigna Commercial PPO 917.13 percent of total billed charges 585.06 1344.06 58% of Billed Charges/$500 Threshold GRACILIS TENDON GRAFT C1762 HCPCS 278 RC inpatient 1581.25 790.63 IMA of Louisiana Commercial PPO 1344.06 percent of total billed charges 790.63 1344.06 Inpatient Reimbursement at 85% of Billed Charges GRACILIS TENDON GRAFT C1762 HCPCS 278 RC outpatient 1581.25 1265 IMA of Louisiana Commercial PPO 1344.06 percent of total billed charges 585.06 1344.06 Reimbursement at 85% of billed charges GRACILIS TENDON GRAFT C1762 HCPCS 278 RC outpatient 1581.25 1265 Aetna Commercial PPO 585.06 percent of total billed charges 585.06 1344.06 37% Of Billed Charges 2000 WALKER BARIATRIC WITH WHEELS 270 RC inpatient 439.82 219.91 BCBS Louisiana PPO 219.91 percent of total billed charges 219.91 373.85 50% of Eligible Charges WALKER BARIATRIC WITH WHEELS 270 RC outpatient 439.82 351.86 BCBS Louisiana PPO 351.86 percent of total billed charges 241.9 373.85 80% of billed charge WALKER BARIATRIC WITH WHEELS 270 RC outpatient 439.82 351.86 Cigna Commercial PPO 241.9 percent of total billed charges 241.9 373.85 55% of Billed Charges WALKER BARIATRIC WITH WHEELS 270 RC inpatient 439.82 219.91 IMA of Louisiana Commercial PPO 373.85 percent of total billed charges 219.91 373.85 Inpatient Reimbursement at 85% of Billed Charges WALKER BARIATRIC WITH WHEELS 270 RC outpatient 439.82 351.86 IMA of Louisiana Commercial PPO 373.85 percent of total billed charges 241.9 373.85 Reimbursement at 85% of billed charges WALKER BARIATRIC WITH WHEELS 270 RC outpatient 439.82 351.86 Aetna Commercial PPO 241.9 percent of total billed charges 241.9 373.85 55 of billed Charges SUTURE LASSO 45 CURVE LEFT SD 272 RC inpatient 435.89 217.95 BCBS Louisiana PPO 217.95 percent of total billed charges 217.95 370.51 50% of Eligible Charges SUTURE LASSO 45 CURVE LEFT SD 272 RC outpatient 435.89 348.71 BCBS Louisiana PPO 348.71 percent of total billed charges 239.74 370.51 80% of billed charge SUTURE LASSO 45 CURVE LEFT SD 272 RC outpatient 435.89 348.71 Cigna Commercial PPO 239.74 percent of total billed charges 239.74 370.51 55% of Billed Charges SUTURE LASSO 45 CURVE LEFT SD 272 RC inpatient 435.89 217.95 IMA of Louisiana Commercial PPO 370.51 percent of total billed charges 217.95 370.51 Inpatient Reimbursement at 85% of Billed Charges SUTURE LASSO 45 CURVE LEFT SD 272 RC outpatient 435.89 348.71 IMA of Louisiana Commercial PPO 370.51 percent of total billed charges 239.74 370.51 Reimbursement at 85% of billed charges SUTURE LASSO 45 CURVE LEFT SD 272 RC outpatient 435.89 348.71 Aetna Commercial PPO 239.74 percent of total billed charges 239.74 370.51 55 of billed Charges SUTURE 2 VICRYL TP-1 J880T 272 RC inpatient 12.91 6.46 BCBS Louisiana PPO 6.46 percent of total billed charges 6.46 10.97 50% of Eligible Charges SUTURE 2 VICRYL TP-1 J880T 272 RC outpatient 12.91 10.33 BCBS Louisiana PPO 10.33 percent of total billed charges 7.1 10.97 80% of billed charge SUTURE 2 VICRYL TP-1 J880T 272 RC outpatient 12.91 10.33 Cigna Commercial PPO 7.1 percent of total billed charges 7.1 10.97 55% of Billed Charges SUTURE 2 VICRYL TP-1 J880T 272 RC inpatient 12.91 6.46 IMA of Louisiana Commercial PPO 10.97 percent of total billed charges 6.46 10.97 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2 VICRYL TP-1 J880T 272 RC outpatient 12.91 10.33 IMA of Louisiana Commercial PPO 10.97 percent of total billed charges 7.1 10.97 Reimbursement at 85% of billed charges SUTURE 2 VICRYL TP-1 J880T 272 RC outpatient 12.91 10.33 Aetna Commercial PPO 7.1 percent of total billed charges 7.1 10.97 55 of billed Charges DRAPE IOBAN XL - WITHOUT IODINE 272 RC inpatient 48.02 24.01 BCBS Louisiana PPO 24.01 percent of total billed charges 24.01 40.82 50% of Eligible Charges DRAPE IOBAN XL - WITHOUT IODINE 272 RC outpatient 48.02 38.42 BCBS Louisiana PPO 38.42 percent of total billed charges 26.41 40.82 80% of billed charge DRAPE IOBAN XL - WITHOUT IODINE 272 RC outpatient 48.02 38.42 Cigna Commercial PPO 26.41 percent of total billed charges 26.41 40.82 55% of Billed Charges DRAPE IOBAN XL - WITHOUT IODINE 272 RC inpatient 48.02 24.01 IMA of Louisiana Commercial PPO 40.82 percent of total billed charges 24.01 40.82 Inpatient Reimbursement at 85% of Billed Charges DRAPE IOBAN XL - WITHOUT IODINE 272 RC outpatient 48.02 38.42 IMA of Louisiana Commercial PPO 40.82 percent of total billed charges 26.41 40.82 Reimbursement at 85% of billed charges DRAPE IOBAN XL - WITHOUT IODINE 272 RC outpatient 48.02 38.42 Aetna Commercial PPO 26.41 percent of total billed charges 26.41 40.82 55 of billed Charges WALKER REGULAR ADULT 270 RC inpatient 169.22 84.61 BCBS Louisiana PPO 84.61 percent of total billed charges 84.61 143.84 50% of Eligible Charges WALKER REGULAR ADULT 270 RC outpatient 169.22 135.38 BCBS Louisiana PPO 135.38 percent of total billed charges 93.07 143.84 80% of billed charge WALKER REGULAR ADULT 270 RC outpatient 169.22 135.38 Cigna Commercial PPO 93.07 percent of total billed charges 93.07 143.84 55% of Billed Charges WALKER REGULAR ADULT 270 RC inpatient 169.22 84.61 IMA of Louisiana Commercial PPO 143.84 percent of total billed charges 84.61 143.84 Inpatient Reimbursement at 85% of Billed Charges WALKER REGULAR ADULT 270 RC outpatient 169.22 135.38 IMA of Louisiana Commercial PPO 143.84 percent of total billed charges 93.07 143.84 Reimbursement at 85% of billed charges WALKER REGULAR ADULT 270 RC outpatient 169.22 135.38 Aetna Commercial PPO 93.07 percent of total billed charges 93.07 143.84 55 of billed Charges SUTURE 2-0 PROLENE SH 272 RC inpatient 18.92 9.46 BCBS Louisiana PPO 9.46 percent of total billed charges 9.46 16.08 50% of Eligible Charges SUTURE 2-0 PROLENE SH 272 RC outpatient 18.92 15.14 BCBS Louisiana PPO 15.14 percent of total billed charges 10.41 16.08 80% of billed charge SUTURE 2-0 PROLENE SH 272 RC outpatient 18.92 15.14 Cigna Commercial PPO 10.41 percent of total billed charges 10.41 16.08 55% of Billed Charges SUTURE 2-0 PROLENE SH 272 RC inpatient 18.92 9.46 IMA of Louisiana Commercial PPO 16.08 percent of total billed charges 9.46 16.08 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 PROLENE SH 272 RC outpatient 18.92 15.14 IMA of Louisiana Commercial PPO 16.08 percent of total billed charges 10.41 16.08 Reimbursement at 85% of billed charges SUTURE 2-0 PROLENE SH 272 RC outpatient 18.92 15.14 Aetna Commercial PPO 10.41 percent of total billed charges 10.41 16.08 55 of billed Charges SPINAL TRAY - ANESTHESIA 272 RC inpatient 58.8 29.4 BCBS Louisiana PPO 29.4 percent of total billed charges 29.4 49.98 50% of Eligible Charges SPINAL TRAY - ANESTHESIA 272 RC outpatient 58.8 47.04 BCBS Louisiana PPO 47.04 percent of total billed charges 32.34 49.98 80% of billed charge SPINAL TRAY - ANESTHESIA 272 RC outpatient 58.8 47.04 Cigna Commercial PPO 32.34 percent of total billed charges 32.34 49.98 55% of Billed Charges SPINAL TRAY - ANESTHESIA 272 RC inpatient 58.8 29.4 IMA of Louisiana Commercial PPO 49.98 percent of total billed charges 29.4 49.98 Inpatient Reimbursement at 85% of Billed Charges SPINAL TRAY - ANESTHESIA 272 RC outpatient 58.8 47.04 IMA of Louisiana Commercial PPO 49.98 percent of total billed charges 32.34 49.98 Reimbursement at 85% of billed charges SPINAL TRAY - ANESTHESIA 272 RC outpatient 58.8 47.04 Aetna Commercial PPO 32.34 percent of total billed charges 32.34 49.98 55 of billed Charges PREP PVP IODINE MED 270 RC inpatient 17.04 8.52 BCBS Louisiana PPO 8.52 percent of total billed charges 8.52 14.48 50% of Eligible Charges PREP PVP IODINE MED 270 RC outpatient 17.04 13.63 BCBS Louisiana PPO 13.63 percent of total billed charges 9.37 14.48 80% of billed charge PREP PVP IODINE MED 270 RC outpatient 17.04 13.63 Cigna Commercial PPO 9.37 percent of total billed charges 9.37 14.48 55% of Billed Charges PREP PVP IODINE MED 270 RC inpatient 17.04 8.52 IMA of Louisiana Commercial PPO 14.48 percent of total billed charges 8.52 14.48 Inpatient Reimbursement at 85% of Billed Charges PREP PVP IODINE MED 270 RC outpatient 17.04 13.63 IMA of Louisiana Commercial PPO 14.48 percent of total billed charges 9.37 14.48 Reimbursement at 85% of billed charges PREP PVP IODINE MED 270 RC outpatient 17.04 13.63 Aetna Commercial PPO 9.37 percent of total billed charges 9.37 14.48 55 of billed Charges TUBING OXYGEN SUPPLY FLEX VIN 270 RC inpatient 65.32 32.66 BCBS Louisiana PPO 32.66 percent of total billed charges 32.66 55.52 50% of Eligible Charges TUBING OXYGEN SUPPLY FLEX VIN 270 RC outpatient 65.32 52.26 BCBS Louisiana PPO 52.26 percent of total billed charges 35.93 55.52 80% of billed charge TUBING OXYGEN SUPPLY FLEX VIN 270 RC outpatient 65.32 52.26 Cigna Commercial PPO 35.93 percent of total billed charges 35.93 55.52 55% of Billed Charges TUBING OXYGEN SUPPLY FLEX VIN 270 RC inpatient 65.32 32.66 IMA of Louisiana Commercial PPO 55.52 percent of total billed charges 32.66 55.52 Inpatient Reimbursement at 85% of Billed Charges TUBING OXYGEN SUPPLY FLEX VIN 270 RC outpatient 65.32 52.26 IMA of Louisiana Commercial PPO 55.52 percent of total billed charges 35.93 55.52 Reimbursement at 85% of billed charges TUBING OXYGEN SUPPLY FLEX VIN 270 RC outpatient 65.32 52.26 Aetna Commercial PPO 35.93 percent of total billed charges 35.93 55.52 55 of billed Charges MASK AEROSOL ELNG W/O TU 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges MASK AEROSOL ELNG W/O TU 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge MASK AEROSOL ELNG W/O TU 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges MASK AEROSOL ELNG W/O TU 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges MASK AEROSOL ELNG W/O TU 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges MASK AEROSOL ELNG W/O TU 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SUCTION ORTHO TIP 272 RC inpatient 7.08 3.54 BCBS Louisiana PPO 3.54 percent of total billed charges 3.54 6.02 50% of Eligible Charges SUCTION ORTHO TIP 272 RC outpatient 7.08 5.66 BCBS Louisiana PPO 5.66 percent of total billed charges 3.89 6.02 80% of billed charge SUCTION ORTHO TIP 272 RC outpatient 7.08 5.66 Cigna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55% of Billed Charges SUCTION ORTHO TIP 272 RC inpatient 7.08 3.54 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.54 6.02 Inpatient Reimbursement at 85% of Billed Charges SUCTION ORTHO TIP 272 RC outpatient 7.08 5.66 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.89 6.02 Reimbursement at 85% of billed charges SUCTION ORTHO TIP 272 RC outpatient 7.08 5.66 Aetna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55 of billed Charges BEDPAN REGULAR 270 RC inpatient 10.58 5.29 BCBS Louisiana PPO 5.29 percent of total billed charges 5.29 8.99 50% of Eligible Charges BEDPAN REGULAR 270 RC outpatient 10.58 8.46 BCBS Louisiana PPO 8.46 percent of total billed charges 5.82 8.99 80% of billed charge BEDPAN REGULAR 270 RC outpatient 10.58 8.46 Cigna Commercial PPO 5.82 percent of total billed charges 5.82 8.99 55% of Billed Charges BEDPAN REGULAR 270 RC inpatient 10.58 5.29 IMA of Louisiana Commercial PPO 8.99 percent of total billed charges 5.29 8.99 Inpatient Reimbursement at 85% of Billed Charges BEDPAN REGULAR 270 RC outpatient 10.58 8.46 IMA of Louisiana Commercial PPO 8.99 percent of total billed charges 5.82 8.99 Reimbursement at 85% of billed charges BEDPAN REGULAR 270 RC outpatient 10.58 8.46 Aetna Commercial PPO 5.82 percent of total billed charges 5.82 8.99 55 of billed Charges TAPE TRANSPARENT LF 1/2 270 RC inpatient 31.44 15.72 BCBS Louisiana PPO 15.72 percent of total billed charges 15.72 26.72 50% of Eligible Charges TAPE TRANSPARENT LF 1/2 270 RC outpatient 31.44 25.15 BCBS Louisiana PPO 25.15 percent of total billed charges 17.29 26.72 80% of billed charge TAPE TRANSPARENT LF 1/2 270 RC outpatient 31.44 25.15 Cigna Commercial PPO 17.29 percent of total billed charges 17.29 26.72 55% of Billed Charges TAPE TRANSPARENT LF 1/2 270 RC inpatient 31.44 15.72 IMA of Louisiana Commercial PPO 26.72 percent of total billed charges 15.72 26.72 Inpatient Reimbursement at 85% of Billed Charges TAPE TRANSPARENT LF 1/2 270 RC outpatient 31.44 25.15 IMA of Louisiana Commercial PPO 26.72 percent of total billed charges 17.29 26.72 Reimbursement at 85% of billed charges TAPE TRANSPARENT LF 1/2 270 RC outpatient 31.44 25.15 Aetna Commercial PPO 17.29 percent of total billed charges 17.29 26.72 55 of billed Charges CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC inpatient 675 337.5 BCBS Louisiana PPO 337.5 percent of total billed charges 337.5 573.75 50% of Eligible Charges CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC outpatient 675 540 BCBS Louisiana PPO 540 percent of total billed charges 249.75 573.75 80% of billed charge CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC outpatient 675 540 Cigna Commercial PPO 391.5 percent of total billed charges 249.75 573.75 58% of Billed Charges/$500 Threshold CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC inpatient 675 337.5 IMA of Louisiana Commercial PPO 573.75 percent of total billed charges 337.5 573.75 Inpatient Reimbursement at 85% of Billed Charges CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC outpatient 675 540 IMA of Louisiana Commercial PPO 573.75 percent of total billed charges 249.75 573.75 Reimbursement at 85% of billed charges CEMENT HV/SIMPLEX 40G- C1713 HCPCS 278 RC outpatient 675 540 Aetna Commercial PPO 249.75 percent of total billed charges 249.75 573.75 37% Of Billed Charges 2000 TUBE SHILEY XLT TRACH 8MM ID 272 RC inpatient 171.33 85.67 BCBS Louisiana PPO 85.67 percent of total billed charges 85.67 145.63 50% of Eligible Charges TUBE SHILEY XLT TRACH 8MM ID 272 RC outpatient 171.33 137.06 BCBS Louisiana PPO 137.06 percent of total billed charges 94.23 145.63 80% of billed charge TUBE SHILEY XLT TRACH 8MM ID 272 RC outpatient 171.33 137.06 Cigna Commercial PPO 94.23 percent of total billed charges 94.23 145.63 55% of Billed Charges TUBE SHILEY XLT TRACH 8MM ID 272 RC inpatient 171.33 85.67 IMA of Louisiana Commercial PPO 145.63 percent of total billed charges 85.67 145.63 Inpatient Reimbursement at 85% of Billed Charges TUBE SHILEY XLT TRACH 8MM ID 272 RC outpatient 171.33 137.06 IMA of Louisiana Commercial PPO 145.63 percent of total billed charges 94.23 145.63 Reimbursement at 85% of billed charges TUBE SHILEY XLT TRACH 8MM ID 272 RC outpatient 171.33 137.06 Aetna Commercial PPO 94.23 percent of total billed charges 94.23 145.63 55 of billed Charges SUTURE 2-0 PROLENE CT-2 272 RC inpatient 12.08 6.04 BCBS Louisiana PPO 6.04 percent of total billed charges 6.04 10.27 50% of Eligible Charges SUTURE 2-0 PROLENE CT-2 272 RC outpatient 12.08 9.66 BCBS Louisiana PPO 9.66 percent of total billed charges 6.64 10.27 80% of billed charge SUTURE 2-0 PROLENE CT-2 272 RC outpatient 12.08 9.66 Cigna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55% of Billed Charges SUTURE 2-0 PROLENE CT-2 272 RC inpatient 12.08 6.04 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.04 10.27 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 PROLENE CT-2 272 RC outpatient 12.08 9.66 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.64 10.27 Reimbursement at 85% of billed charges SUTURE 2-0 PROLENE CT-2 272 RC outpatient 12.08 9.66 Aetna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55 of billed Charges SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC inpatient 375.33 187.67 BCBS Louisiana PPO 187.67 percent of total billed charges 187.67 319.03 50% of Eligible Charges SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC outpatient 375.33 300.26 BCBS Louisiana PPO 300.26 percent of total billed charges 138.87 319.03 80% of billed charge SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC outpatient 375.33 300.26 Cigna Commercial PPO 217.69 percent of total billed charges 138.87 319.03 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC inpatient 375.33 187.67 IMA of Louisiana Commercial PPO 319.03 percent of total billed charges 187.67 319.03 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC outpatient 375.33 300.26 IMA of Louisiana Commercial PPO 319.03 percent of total billed charges 138.87 319.03 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 02.212.056 C1713 HCPCS 278 RC outpatient 375.33 300.26 Aetna Commercial PPO 138.87 percent of total billed charges 138.87 319.03 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 68MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 TISSEEL FIBRIN SEALANT C9250 HCPCS 278 RC inpatient 514.74 257.37 BCBS Louisiana PPO 257.37 percent of total billed charges 257.37 437.53 50% of Eligible Charges TISSEEL FIBRIN SEALANT C9250 HCPCS 278 RC outpatient 514.74 411.79 BCBS Louisiana PPO 411.79 percent of total billed charges 298.55 437.53 80% of billed charge TISSEEL FIBRIN SEALANT C9250 HCPCS 278 RC outpatient 514.74 411.79 Cigna Commercial PPO 298.55 percent of total billed charges 298.55 437.53 58% of Billed Charges/$500 Threshold TISSEEL FIBRIN SEALANT C9250 HCPCS 278 RC inpatient 514.74 257.37 IMA of Louisiana Commercial PPO 437.53 percent of total billed charges 257.37 437.53 Inpatient Reimbursement at 85% of Billed Charges TISSEEL FIBRIN SEALANT C9250 HCPCS 278 RC outpatient 514.74 411.79 IMA of Louisiana Commercial PPO 437.53 percent of total billed charges 298.55 437.53 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 8.5 272 RC inpatient 6.52 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 3.26 5.54 50% of Eligible Charges GLOVE LATEX FREE SZ 8.5 272 RC outpatient 6.52 5.22 BCBS Louisiana PPO 5.22 percent of total billed charges 3.59 5.54 80% of billed charge GLOVE LATEX FREE SZ 8.5 272 RC outpatient 6.52 5.22 Cigna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55% of Billed Charges GLOVE LATEX FREE SZ 8.5 272 RC inpatient 6.52 3.26 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.26 5.54 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 8.5 272 RC outpatient 6.52 5.22 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.59 5.54 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 8.5 272 RC outpatient 6.52 5.22 Aetna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55 of billed Charges SPECIMEN STERILE CONTAINER - COOPER 272 RC inpatient 121.35 60.68 BCBS Louisiana PPO 60.68 percent of total billed charges 60.68 103.15 50% of Eligible Charges SPECIMEN STERILE CONTAINER - COOPER 272 RC outpatient 121.35 97.08 BCBS Louisiana PPO 97.08 percent of total billed charges 66.74 103.15 80% of billed charge SPECIMEN STERILE CONTAINER - COOPER 272 RC outpatient 121.35 97.08 Cigna Commercial PPO 66.74 percent of total billed charges 66.74 103.15 55% of Billed Charges SPECIMEN STERILE CONTAINER - COOPER 272 RC inpatient 121.35 60.68 IMA of Louisiana Commercial PPO 103.15 percent of total billed charges 60.68 103.15 Inpatient Reimbursement at 85% of Billed Charges SPECIMEN STERILE CONTAINER - COOPER 272 RC outpatient 121.35 97.08 IMA of Louisiana Commercial PPO 103.15 percent of total billed charges 66.74 103.15 Reimbursement at 85% of billed charges SPECIMEN STERILE CONTAINER - COOPER 272 RC outpatient 121.35 97.08 Aetna Commercial PPO 66.74 percent of total billed charges 66.74 103.15 55 of billed Charges SAW BLADE 2108-100 272 RC inpatient 82.84 41.42 BCBS Louisiana PPO 41.42 percent of total billed charges 41.42 70.41 50% of Eligible Charges SAW BLADE 2108-100 272 RC outpatient 82.84 66.27 BCBS Louisiana PPO 66.27 percent of total billed charges 45.56 70.41 80% of billed charge SAW BLADE 2108-100 272 RC outpatient 82.84 66.27 Cigna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55% of Billed Charges SAW BLADE 2108-100 272 RC inpatient 82.84 41.42 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 41.42 70.41 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-100 272 RC outpatient 82.84 66.27 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 45.56 70.41 Reimbursement at 85% of billed charges SAW BLADE 2108-100 272 RC outpatient 82.84 66.27 Aetna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55 of billed Charges CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC inpatient 784.8 392.4 BCBS Louisiana PPO 392.4 percent of total billed charges 392.4 667.08 50% of Eligible Charges CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC outpatient 784.8 627.84 BCBS Louisiana PPO 627.84 percent of total billed charges 431.64 667.08 80% of billed charge CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC outpatient 784.8 627.84 Cigna Commercial PPO 431.64 percent of total billed charges 431.64 667.08 55% of Billed Charges CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC inpatient 784.8 392.4 IMA of Louisiana Commercial PPO 667.08 percent of total billed charges 392.4 667.08 Inpatient Reimbursement at 85% of Billed Charges CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC outpatient 784.8 627.84 IMA of Louisiana Commercial PPO 667.08 percent of total billed charges 431.64 667.08 Reimbursement at 85% of billed charges CEMENT MIXER FEMERAL NOZZLE 306-563 272 RC outpatient 784.8 627.84 Aetna Commercial PPO 431.64 percent of total billed charges 431.64 667.08 55 of billed Charges IV PUMP TUBING -DEDICATED TUBING 272 RC inpatient 24.48 12.24 BCBS Louisiana PPO 12.24 percent of total billed charges 12.24 20.81 50% of Eligible Charges IV PUMP TUBING -DEDICATED TUBING 272 RC outpatient 24.48 19.58 BCBS Louisiana PPO 19.58 percent of total billed charges 13.46 20.81 80% of billed charge IV PUMP TUBING -DEDICATED TUBING 272 RC outpatient 24.48 19.58 Cigna Commercial PPO 13.46 percent of total billed charges 13.46 20.81 55% of Billed Charges IV PUMP TUBING -DEDICATED TUBING 272 RC inpatient 24.48 12.24 IMA of Louisiana Commercial PPO 20.81 percent of total billed charges 12.24 20.81 Inpatient Reimbursement at 85% of Billed Charges IV PUMP TUBING -DEDICATED TUBING 272 RC outpatient 24.48 19.58 IMA of Louisiana Commercial PPO 20.81 percent of total billed charges 13.46 20.81 Reimbursement at 85% of billed charges IV PUMP TUBING -DEDICATED TUBING 272 RC outpatient 24.48 19.58 Aetna Commercial PPO 13.46 percent of total billed charges 13.46 20.81 55 of billed Charges DRAIN 10MM FLAT 272 RC inpatient 37.76 18.88 BCBS Louisiana PPO 18.88 percent of total billed charges 18.88 32.1 50% of Eligible Charges DRAIN 10MM FLAT 272 RC outpatient 37.76 30.21 BCBS Louisiana PPO 30.21 percent of total billed charges 20.77 32.1 80% of billed charge DRAIN 10MM FLAT 272 RC outpatient 37.76 30.21 Cigna Commercial PPO 20.77 percent of total billed charges 20.77 32.1 55% of Billed Charges DRAIN 10MM FLAT 272 RC inpatient 37.76 18.88 IMA of Louisiana Commercial PPO 32.1 percent of total billed charges 18.88 32.1 Inpatient Reimbursement at 85% of Billed Charges DRAIN 10MM FLAT 272 RC outpatient 37.76 30.21 IMA of Louisiana Commercial PPO 32.1 percent of total billed charges 20.77 32.1 Reimbursement at 85% of billed charges DRAIN 10MM FLAT 272 RC outpatient 37.76 30.21 Aetna Commercial PPO 20.77 percent of total billed charges 20.77 32.1 55 of billed Charges BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 511 255.5 BCBS Louisiana PPO 255.5 percent of total billed charges 255.5 434.35 50% of Eligible Charges BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 511 408.8 BCBS Louisiana PPO 408.8 percent of total billed charges 189.07 434.35 80% of billed charge BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 511 408.8 Cigna Commercial PPO 296.38 percent of total billed charges 189.07 434.35 58% of Billed Charges/$500 Threshold BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 511 255.5 IMA of Louisiana Commercial PPO 434.35 percent of total billed charges 255.5 434.35 Inpatient Reimbursement at 85% of Billed Charges BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 511 408.8 IMA of Louisiana Commercial PPO 434.35 percent of total billed charges 189.07 434.35 Reimbursement at 85% of billed charges BONE 5CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 511 408.8 Aetna Commercial PPO 189.07 percent of total billed charges 189.07 434.35 37% Of Billed Charges 2000 SHOE POST-OP MALE LG 270 RC inpatient 21.24 10.62 BCBS Louisiana PPO 10.62 percent of total billed charges 10.62 18.05 50% of Eligible Charges SHOE POST-OP MALE LG 270 RC outpatient 21.24 16.99 BCBS Louisiana PPO 16.99 percent of total billed charges 11.68 18.05 80% of billed charge SHOE POST-OP MALE LG 270 RC outpatient 21.24 16.99 Cigna Commercial PPO 11.68 percent of total billed charges 11.68 18.05 55% of Billed Charges SHOE POST-OP MALE LG 270 RC inpatient 21.24 10.62 IMA of Louisiana Commercial PPO 18.05 percent of total billed charges 10.62 18.05 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP MALE LG 270 RC outpatient 21.24 16.99 IMA of Louisiana Commercial PPO 18.05 percent of total billed charges 11.68 18.05 Reimbursement at 85% of billed charges SHOE POST-OP MALE LG 270 RC outpatient 21.24 16.99 Aetna Commercial PPO 11.68 percent of total billed charges 11.68 18.05 55 of billed Charges SHOE POST-OP MALE MED STATMD 270 RC inpatient 21.04 10.52 BCBS Louisiana PPO 10.52 percent of total billed charges 10.52 17.88 50% of Eligible Charges SHOE POST-OP MALE MED STATMD 270 RC outpatient 21.04 16.83 BCBS Louisiana PPO 16.83 percent of total billed charges 11.57 17.88 80% of billed charge SHOE POST-OP MALE MED STATMD 270 RC outpatient 21.04 16.83 Cigna Commercial PPO 11.57 percent of total billed charges 11.57 17.88 55% of Billed Charges SHOE POST-OP MALE MED STATMD 270 RC inpatient 21.04 10.52 IMA of Louisiana Commercial PPO 17.88 percent of total billed charges 10.52 17.88 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP MALE MED STATMD 270 RC outpatient 21.04 16.83 IMA of Louisiana Commercial PPO 17.88 percent of total billed charges 11.57 17.88 Reimbursement at 85% of billed charges SHOE POST-OP MALE MED STATMD 270 RC outpatient 21.04 16.83 Aetna Commercial PPO 11.57 percent of total billed charges 11.57 17.88 55 of billed Charges ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC inpatient 1657.5 828.75 BCBS Louisiana PPO 828.75 percent of total billed charges 828.75 1408.88 50% of Eligible Charges ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC outpatient 1657.5 1326 BCBS Louisiana PPO 1326 percent of total billed charges 613.28 1408.88 80% of billed charge ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC outpatient 1657.5 1326 Cigna Commercial PPO 961.35 percent of total billed charges 613.28 1408.88 58% of Billed Charges/$500 Threshold ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC inpatient 1657.5 828.75 IMA of Louisiana Commercial PPO 1408.88 percent of total billed charges 828.75 1408.88 Inpatient Reimbursement at 85% of Billed Charges ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC outpatient 1657.5 1326 IMA of Louisiana Commercial PPO 1408.88 percent of total billed charges 613.28 1408.88 Reimbursement at 85% of billed charges ANCHOR 5.5 PEEK AR-1927PSF C1713 HCPCS 278 RC outpatient 1657.5 1326 Aetna Commercial PPO 613.28 percent of total billed charges 613.28 1408.88 37% Of Billed Charges 2000 SPONGE 4 X 4 (STERILE) 272 RC inpatient 4.23 2.12 BCBS Louisiana PPO 2.12 percent of total billed charges 2.12 3.6 50% of Eligible Charges SPONGE 4 X 4 (STERILE) 272 RC outpatient 4.23 3.38 BCBS Louisiana PPO 3.38 percent of total billed charges 2.33 3.6 80% of billed charge SPONGE 4 X 4 (STERILE) 272 RC outpatient 4.23 3.38 Cigna Commercial PPO 2.33 percent of total billed charges 2.33 3.6 55% of Billed Charges SPONGE 4 X 4 (STERILE) 272 RC inpatient 4.23 2.12 IMA of Louisiana Commercial PPO 3.6 percent of total billed charges 2.12 3.6 Inpatient Reimbursement at 85% of Billed Charges SPONGE 4 X 4 (STERILE) 272 RC outpatient 4.23 3.38 IMA of Louisiana Commercial PPO 3.6 percent of total billed charges 2.33 3.6 Reimbursement at 85% of billed charges SPONGE 4 X 4 (STERILE) 272 RC outpatient 4.23 3.38 Aetna Commercial PPO 2.33 percent of total billed charges 2.33 3.6 55 of billed Charges STEINMAN PIN THREADED 2.4 272 RC inpatient 455 227.5 BCBS Louisiana PPO 227.5 percent of total billed charges 227.5 386.75 50% of Eligible Charges STEINMAN PIN THREADED 2.4 272 RC outpatient 455 364 BCBS Louisiana PPO 364 percent of total billed charges 250.25 386.75 80% of billed charge STEINMAN PIN THREADED 2.4 272 RC outpatient 455 364 Cigna Commercial PPO 250.25 percent of total billed charges 250.25 386.75 55% of Billed Charges STEINMAN PIN THREADED 2.4 272 RC inpatient 455 227.5 IMA of Louisiana Commercial PPO 386.75 percent of total billed charges 227.5 386.75 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN THREADED 2.4 272 RC outpatient 455 364 IMA of Louisiana Commercial PPO 386.75 percent of total billed charges 250.25 386.75 Reimbursement at 85% of billed charges STEINMAN PIN THREADED 2.4 272 RC outpatient 455 364 Aetna Commercial PPO 250.25 percent of total billed charges 250.25 386.75 55 of billed Charges TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC inpatient 590.82 295.41 BCBS Louisiana PPO 295.41 percent of total billed charges 295.41 502.2 50% of Eligible Charges TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC outpatient 590.82 472.66 BCBS Louisiana PPO 472.66 percent of total billed charges 324.95 502.2 80% of billed charge TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC outpatient 590.82 472.66 Cigna Commercial PPO 324.95 percent of total billed charges 324.95 502.2 55% of Billed Charges TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC inpatient 590.82 295.41 IMA of Louisiana Commercial PPO 502.2 percent of total billed charges 295.41 502.2 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC outpatient 590.82 472.66 IMA of Louisiana Commercial PPO 502.2 percent of total billed charges 324.95 502.2 Reimbursement at 85% of billed charges TOURNIQUET 34'' DISPOSABLE STRYKER 272 RC outpatient 590.82 472.66 Aetna Commercial PPO 324.95 percent of total billed charges 324.95 502.2 55 of billed Charges SUCTION LINER CRD 1500ML 270 RC inpatient 388.48 194.24 BCBS Louisiana PPO 194.24 percent of total billed charges 194.24 330.21 50% of Eligible Charges SUCTION LINER CRD 1500ML 270 RC outpatient 388.48 310.78 BCBS Louisiana PPO 310.78 percent of total billed charges 213.66 330.21 80% of billed charge SUCTION LINER CRD 1500ML 270 RC outpatient 388.48 310.78 Cigna Commercial PPO 213.66 percent of total billed charges 213.66 330.21 55% of Billed Charges SUCTION LINER CRD 1500ML 270 RC inpatient 388.48 194.24 IMA of Louisiana Commercial PPO 330.21 percent of total billed charges 194.24 330.21 Inpatient Reimbursement at 85% of Billed Charges SUCTION LINER CRD 1500ML 270 RC outpatient 388.48 310.78 IMA of Louisiana Commercial PPO 330.21 percent of total billed charges 213.66 330.21 Reimbursement at 85% of billed charges SUCTION LINER CRD 1500ML 270 RC outpatient 388.48 310.78 Aetna Commercial PPO 213.66 percent of total billed charges 213.66 330.21 55 of billed Charges SUCTION YANKAUER TIP 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges SUCTION YANKAUER TIP 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge SUCTION YANKAUER TIP 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges SUCTION YANKAUER TIP 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges SUCTION YANKAUER TIP 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges SUCTION YANKAUER TIP 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC inpatient 57.12 28.56 BCBS Louisiana PPO 28.56 percent of total billed charges 28.56 48.55 50% of Eligible Charges SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC outpatient 57.12 45.7 BCBS Louisiana PPO 45.7 percent of total billed charges 31.42 48.55 80% of billed charge SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC outpatient 57.12 45.7 Cigna Commercial PPO 31.42 percent of total billed charges 31.42 48.55 55% of Billed Charges SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC inpatient 57.12 28.56 IMA of Louisiana Commercial PPO 48.55 percent of total billed charges 28.56 48.55 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC outpatient 57.12 45.7 IMA of Louisiana Commercial PPO 48.55 percent of total billed charges 31.42 48.55 Reimbursement at 85% of billed charges SUTURE 0 ETHIBOND MO-7 CR CX41D 272 RC outpatient 57.12 45.7 Aetna Commercial PPO 31.42 percent of total billed charges 31.42 48.55 55 of billed Charges SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC inpatient 47.32 23.66 BCBS Louisiana PPO 23.66 percent of total billed charges 23.66 40.22 50% of Eligible Charges SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC outpatient 47.32 37.86 BCBS Louisiana PPO 37.86 percent of total billed charges 26.03 40.22 80% of billed charge SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC outpatient 47.32 37.86 Cigna Commercial PPO 26.03 percent of total billed charges 26.03 40.22 55% of Billed Charges SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC inpatient 47.32 23.66 IMA of Louisiana Commercial PPO 40.22 percent of total billed charges 23.66 40.22 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC outpatient 47.32 37.86 IMA of Louisiana Commercial PPO 40.22 percent of total billed charges 26.03 40.22 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL CT-1 CR J839D 272 RC outpatient 47.32 37.86 Aetna Commercial PPO 26.03 percent of total billed charges 26.03 40.22 55 of billed Charges EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC inpatient 56.49 28.25 BCBS Louisiana PPO 28.25 percent of total billed charges 28.25 48.02 50% of Eligible Charges EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC outpatient 56.49 45.19 BCBS Louisiana PPO 45.19 percent of total billed charges 31.07 48.02 80% of billed charge EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC outpatient 56.49 45.19 Cigna Commercial PPO 31.07 percent of total billed charges 31.07 48.02 55% of Billed Charges EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC inpatient 56.49 28.25 IMA of Louisiana Commercial PPO 48.02 percent of total billed charges 28.25 48.02 Inpatient Reimbursement at 85% of Billed Charges EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC outpatient 56.49 45.19 IMA of Louisiana Commercial PPO 48.02 percent of total billed charges 31.07 48.02 Reimbursement at 85% of billed charges EPIDURAL CONTINUOUS ANES. SET - LETCHUMA 272 RC outpatient 56.49 45.19 Aetna Commercial PPO 31.07 percent of total billed charges 31.07 48.02 55 of billed Charges SYRINGE 3CC 22 X 1 1/2 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE 3CC 22 X 1 1/2 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE 3CC 22 X 1 1/2 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE 3CC 22 X 1 1/2 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 3CC 22 X 1 1/2 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE 3CC 22 X 1 1/2 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SYRINGE GLASS 5CC LUER-SLIP 272 RC inpatient 210.7 105.35 BCBS Louisiana PPO 105.35 percent of total billed charges 105.35 179.1 50% of Eligible Charges SYRINGE GLASS 5CC LUER-SLIP 272 RC outpatient 210.7 168.56 BCBS Louisiana PPO 168.56 percent of total billed charges 115.89 179.1 80% of billed charge SYRINGE GLASS 5CC LUER-SLIP 272 RC outpatient 210.7 168.56 Cigna Commercial PPO 115.89 percent of total billed charges 115.89 179.1 55% of Billed Charges SYRINGE GLASS 5CC LUER-SLIP 272 RC inpatient 210.7 105.35 IMA of Louisiana Commercial PPO 179.1 percent of total billed charges 105.35 179.1 Inpatient Reimbursement at 85% of Billed Charges SYRINGE GLASS 5CC LUER-SLIP 272 RC outpatient 210.7 168.56 IMA of Louisiana Commercial PPO 179.1 percent of total billed charges 115.89 179.1 Reimbursement at 85% of billed charges SYRINGE GLASS 5CC LUER-SLIP 272 RC outpatient 210.7 168.56 Aetna Commercial PPO 115.89 percent of total billed charges 115.89 179.1 55 of billed Charges DRAIN BULB 100CC RES. 272 RC inpatient 15.84 7.92 BCBS Louisiana PPO 7.92 percent of total billed charges 7.92 13.46 50% of Eligible Charges DRAIN BULB 100CC RES. 272 RC outpatient 15.84 12.67 BCBS Louisiana PPO 12.67 percent of total billed charges 8.71 13.46 80% of billed charge DRAIN BULB 100CC RES. 272 RC outpatient 15.84 12.67 Cigna Commercial PPO 8.71 percent of total billed charges 8.71 13.46 55% of Billed Charges DRAIN BULB 100CC RES. 272 RC inpatient 15.84 7.92 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 7.92 13.46 Inpatient Reimbursement at 85% of Billed Charges DRAIN BULB 100CC RES. 272 RC outpatient 15.84 12.67 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 8.71 13.46 Reimbursement at 85% of billed charges DRAIN BULB 100CC RES. 272 RC outpatient 15.84 12.67 Aetna Commercial PPO 8.71 percent of total billed charges 8.71 13.46 55 of billed Charges WATER STERILE 1000ML IRRIGATION 272 RC inpatient 11.42 5.71 BCBS Louisiana PPO 5.71 percent of total billed charges 5.71 9.71 50% of Eligible Charges WATER STERILE 1000ML IRRIGATION 272 RC outpatient 11.42 9.14 BCBS Louisiana PPO 9.14 percent of total billed charges 6.28 9.71 80% of billed charge WATER STERILE 1000ML IRRIGATION 272 RC outpatient 11.42 9.14 Cigna Commercial PPO 6.28 percent of total billed charges 6.28 9.71 55% of Billed Charges WATER STERILE 1000ML IRRIGATION 272 RC inpatient 11.42 5.71 IMA of Louisiana Commercial PPO 9.71 percent of total billed charges 5.71 9.71 Inpatient Reimbursement at 85% of Billed Charges WATER STERILE 1000ML IRRIGATION 272 RC outpatient 11.42 9.14 IMA of Louisiana Commercial PPO 9.71 percent of total billed charges 6.28 9.71 Reimbursement at 85% of billed charges WATER STERILE 1000ML IRRIGATION 272 RC outpatient 11.42 9.14 Aetna Commercial PPO 6.28 percent of total billed charges 6.28 9.71 55 of billed Charges BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC inpatient 2322.9 1161.45 BCBS Louisiana PPO 1161.45 percent of total billed charges 1161.45 1974.47 50% of Eligible Charges BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC outpatient 2322.9 1858.32 BCBS Louisiana PPO 1858.32 percent of total billed charges 859.47 1974.47 80% of billed charge BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC outpatient 2322.9 1858.32 Cigna Commercial PPO 1347.28 percent of total billed charges 859.47 1974.47 58% of Billed Charges/$500 Threshold BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC inpatient 2322.9 1161.45 IMA of Louisiana Commercial PPO 1974.47 percent of total billed charges 1161.45 1974.47 Inpatient Reimbursement at 85% of Billed Charges BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC outpatient 2322.9 1858.32 IMA of Louisiana Commercial PPO 1974.47 percent of total billed charges 859.47 1974.47 Reimbursement at 85% of billed charges BONE TIBIA DISTAL RIGHT L25.5 C1713 HCPCS 278 RC outpatient 2322.9 1858.32 Aetna Commercial PPO 859.47 percent of total billed charges 859.47 1974.47 37% Of Billed Charges 2000 GLOVE ESTEEM LF PF SZ 9 272 RC inpatient 466.52 233.26 BCBS Louisiana PPO 233.26 percent of total billed charges 233.26 396.54 50% of Eligible Charges GLOVE ESTEEM LF PF SZ 9 272 RC outpatient 466.52 373.22 BCBS Louisiana PPO 373.22 percent of total billed charges 256.59 396.54 80% of billed charge GLOVE ESTEEM LF PF SZ 9 272 RC outpatient 466.52 373.22 Cigna Commercial PPO 256.59 percent of total billed charges 256.59 396.54 55% of Billed Charges GLOVE ESTEEM LF PF SZ 9 272 RC inpatient 466.52 233.26 IMA of Louisiana Commercial PPO 396.54 percent of total billed charges 233.26 396.54 Inpatient Reimbursement at 85% of Billed Charges GLOVE ESTEEM LF PF SZ 9 272 RC outpatient 466.52 373.22 IMA of Louisiana Commercial PPO 396.54 percent of total billed charges 256.59 396.54 Reimbursement at 85% of billed charges GLOVE ESTEEM LF PF SZ 9 272 RC outpatient 466.52 373.22 Aetna Commercial PPO 256.59 percent of total billed charges 256.59 396.54 55 of billed Charges AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC inpatient 248.64 124.32 BCBS Louisiana PPO 124.32 percent of total billed charges 124.32 211.34 50% of Eligible Charges AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC outpatient 248.64 198.91 BCBS Louisiana PPO 198.91 percent of total billed charges 136.75 211.34 80% of billed charge AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC outpatient 248.64 198.91 Cigna Commercial PPO 136.75 percent of total billed charges 136.75 211.34 55% of Billed Charges AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC inpatient 248.64 124.32 IMA of Louisiana Commercial PPO 211.34 percent of total billed charges 124.32 211.34 Inpatient Reimbursement at 85% of Billed Charges AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC outpatient 248.64 198.91 IMA of Louisiana Commercial PPO 211.34 percent of total billed charges 136.75 211.34 Reimbursement at 85% of billed charges AMBU BAG MANUAL RESUSICITATOR ADULT 270 RC outpatient 248.64 198.91 Aetna Commercial PPO 136.75 percent of total billed charges 136.75 211.34 55 of billed Charges MASK OXY HIGH CONC NONREBREATH 270 RC inpatient 6.82 3.41 BCBS Louisiana PPO 3.41 percent of total billed charges 3.41 5.8 50% of Eligible Charges MASK OXY HIGH CONC NONREBREATH 270 RC outpatient 6.82 5.46 BCBS Louisiana PPO 5.46 percent of total billed charges 3.75 5.8 80% of billed charge MASK OXY HIGH CONC NONREBREATH 270 RC outpatient 6.82 5.46 Cigna Commercial PPO 3.75 percent of total billed charges 3.75 5.8 55% of Billed Charges MASK OXY HIGH CONC NONREBREATH 270 RC inpatient 6.82 3.41 IMA of Louisiana Commercial PPO 5.8 percent of total billed charges 3.41 5.8 Inpatient Reimbursement at 85% of Billed Charges MASK OXY HIGH CONC NONREBREATH 270 RC outpatient 6.82 5.46 IMA of Louisiana Commercial PPO 5.8 percent of total billed charges 3.75 5.8 Reimbursement at 85% of billed charges MASK OXY HIGH CONC NONREBREATH 270 RC outpatient 6.82 5.46 Aetna Commercial PPO 3.75 percent of total billed charges 3.75 5.8 55 of billed Charges CATHETER TRAY IN/OUT 272 RC inpatient 24.36 12.18 BCBS Louisiana PPO 12.18 percent of total billed charges 12.18 20.71 50% of Eligible Charges CATHETER TRAY IN/OUT 272 RC outpatient 24.36 19.49 BCBS Louisiana PPO 19.49 percent of total billed charges 13.4 20.71 80% of billed charge CATHETER TRAY IN/OUT 272 RC outpatient 24.36 19.49 Cigna Commercial PPO 13.4 percent of total billed charges 13.4 20.71 55% of Billed Charges CATHETER TRAY IN/OUT 272 RC inpatient 24.36 12.18 IMA of Louisiana Commercial PPO 20.71 percent of total billed charges 12.18 20.71 Inpatient Reimbursement at 85% of Billed Charges CATHETER TRAY IN/OUT 272 RC outpatient 24.36 19.49 IMA of Louisiana Commercial PPO 20.71 percent of total billed charges 13.4 20.71 Reimbursement at 85% of billed charges CATHETER TRAY IN/OUT 272 RC outpatient 24.36 19.49 Aetna Commercial PPO 13.4 percent of total billed charges 13.4 20.71 55 of billed Charges SHOULDER IMMOBILIZER SMALL 270 RC inpatient 29.28 14.64 BCBS Louisiana PPO 14.64 percent of total billed charges 14.64 24.89 50% of Eligible Charges SHOULDER IMMOBILIZER SMALL 270 RC outpatient 29.28 23.42 BCBS Louisiana PPO 23.42 percent of total billed charges 16.1 24.89 80% of billed charge SHOULDER IMMOBILIZER SMALL 270 RC outpatient 29.28 23.42 Cigna Commercial PPO 16.1 percent of total billed charges 16.1 24.89 55% of Billed Charges SHOULDER IMMOBILIZER SMALL 270 RC inpatient 29.28 14.64 IMA of Louisiana Commercial PPO 24.89 percent of total billed charges 14.64 24.89 Inpatient Reimbursement at 85% of Billed Charges SHOULDER IMMOBILIZER SMALL 270 RC outpatient 29.28 23.42 IMA of Louisiana Commercial PPO 24.89 percent of total billed charges 16.1 24.89 Reimbursement at 85% of billed charges SHOULDER IMMOBILIZER SMALL 270 RC outpatient 29.28 23.42 Aetna Commercial PPO 16.1 percent of total billed charges 16.1 24.89 55 of billed Charges SUTURE 1 VICRYL CP-1 J268H 272 RC inpatient 7.08 3.54 BCBS Louisiana PPO 3.54 percent of total billed charges 3.54 6.02 50% of Eligible Charges SUTURE 1 VICRYL CP-1 J268H 272 RC outpatient 7.08 5.66 BCBS Louisiana PPO 5.66 percent of total billed charges 3.89 6.02 80% of billed charge SUTURE 1 VICRYL CP-1 J268H 272 RC outpatient 7.08 5.66 Cigna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55% of Billed Charges SUTURE 1 VICRYL CP-1 J268H 272 RC inpatient 7.08 3.54 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.54 6.02 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 VICRYL CP-1 J268H 272 RC outpatient 7.08 5.66 IMA of Louisiana Commercial PPO 6.02 percent of total billed charges 3.89 6.02 Reimbursement at 85% of billed charges SUTURE 1 VICRYL CP-1 J268H 272 RC outpatient 7.08 5.66 Aetna Commercial PPO 3.89 percent of total billed charges 3.89 6.02 55 of billed Charges SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. 72MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 CATHETER COUDE LUB 14 FR 272 RC inpatient 326.34 163.17 BCBS Louisiana PPO 163.17 percent of total billed charges 163.17 277.39 50% of Eligible Charges CATHETER COUDE LUB 14 FR 272 RC outpatient 326.34 261.07 BCBS Louisiana PPO 261.07 percent of total billed charges 179.49 277.39 80% of billed charge CATHETER COUDE LUB 14 FR 272 RC outpatient 326.34 261.07 Cigna Commercial PPO 179.49 percent of total billed charges 179.49 277.39 55% of Billed Charges CATHETER COUDE LUB 14 FR 272 RC inpatient 326.34 163.17 IMA of Louisiana Commercial PPO 277.39 percent of total billed charges 163.17 277.39 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LUB 14 FR 272 RC outpatient 326.34 261.07 IMA of Louisiana Commercial PPO 277.39 percent of total billed charges 179.49 277.39 Reimbursement at 85% of billed charges CATHETER COUDE LUB 14 FR 272 RC outpatient 326.34 261.07 Aetna Commercial PPO 179.49 percent of total billed charges 179.49 277.39 55 of billed Charges DRAIN CLOSED WND SCTN. MED 1/8 272 RC inpatient 103.85 51.93 BCBS Louisiana PPO 51.93 percent of total billed charges 51.93 88.27 50% of Eligible Charges DRAIN CLOSED WND SCTN. MED 1/8 272 RC outpatient 103.85 83.08 BCBS Louisiana PPO 83.08 percent of total billed charges 57.12 88.27 80% of billed charge DRAIN CLOSED WND SCTN. MED 1/8 272 RC outpatient 103.85 83.08 Cigna Commercial PPO 57.12 percent of total billed charges 57.12 88.27 55% of Billed Charges DRAIN CLOSED WND SCTN. MED 1/8 272 RC inpatient 103.85 51.93 IMA of Louisiana Commercial PPO 88.27 percent of total billed charges 51.93 88.27 Inpatient Reimbursement at 85% of Billed Charges DRAIN CLOSED WND SCTN. MED 1/8 272 RC outpatient 103.85 83.08 IMA of Louisiana Commercial PPO 88.27 percent of total billed charges 57.12 88.27 Reimbursement at 85% of billed charges DRAIN CLOSED WND SCTN. MED 1/8 272 RC outpatient 103.85 83.08 Aetna Commercial PPO 57.12 percent of total billed charges 57.12 88.27 55 of billed Charges CLIPPER LIGATIN APPLIER MD/LNG 272 RC inpatient 243.15 121.58 BCBS Louisiana PPO 121.58 percent of total billed charges 121.58 206.68 50% of Eligible Charges CLIPPER LIGATIN APPLIER MD/LNG 272 RC outpatient 243.15 194.52 BCBS Louisiana PPO 194.52 percent of total billed charges 133.73 206.68 80% of billed charge CLIPPER LIGATIN APPLIER MD/LNG 272 RC outpatient 243.15 194.52 Cigna Commercial PPO 133.73 percent of total billed charges 133.73 206.68 55% of Billed Charges CLIPPER LIGATIN APPLIER MD/LNG 272 RC inpatient 243.15 121.58 IMA of Louisiana Commercial PPO 206.68 percent of total billed charges 121.58 206.68 Inpatient Reimbursement at 85% of Billed Charges CLIPPER LIGATIN APPLIER MD/LNG 272 RC outpatient 243.15 194.52 IMA of Louisiana Commercial PPO 206.68 percent of total billed charges 133.73 206.68 Reimbursement at 85% of billed charges CLIPPER LIGATIN APPLIER MD/LNG 272 RC outpatient 243.15 194.52 Aetna Commercial PPO 133.73 percent of total billed charges 133.73 206.68 55 of billed Charges GLOVE LATEX FREE SZ 7.5 272 RC inpatient 6.52 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 3.26 5.54 50% of Eligible Charges GLOVE LATEX FREE SZ 7.5 272 RC outpatient 6.52 5.22 BCBS Louisiana PPO 5.22 percent of total billed charges 3.59 5.54 80% of billed charge GLOVE LATEX FREE SZ 7.5 272 RC outpatient 6.52 5.22 Cigna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55% of Billed Charges GLOVE LATEX FREE SZ 7.5 272 RC inpatient 6.52 3.26 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.26 5.54 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 7.5 272 RC outpatient 6.52 5.22 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.59 5.54 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 7.5 272 RC outpatient 6.52 5.22 Aetna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55 of billed Charges STAPLE SKIN REMOVAL KITS 272 RC inpatient 92.68 46.34 BCBS Louisiana PPO 46.34 percent of total billed charges 46.34 78.78 50% of Eligible Charges STAPLE SKIN REMOVAL KITS 272 RC outpatient 92.68 74.14 BCBS Louisiana PPO 74.14 percent of total billed charges 50.97 78.78 80% of billed charge STAPLE SKIN REMOVAL KITS 272 RC outpatient 92.68 74.14 Cigna Commercial PPO 50.97 percent of total billed charges 50.97 78.78 55% of Billed Charges STAPLE SKIN REMOVAL KITS 272 RC inpatient 92.68 46.34 IMA of Louisiana Commercial PPO 78.78 percent of total billed charges 46.34 78.78 Inpatient Reimbursement at 85% of Billed Charges STAPLE SKIN REMOVAL KITS 272 RC outpatient 92.68 74.14 IMA of Louisiana Commercial PPO 78.78 percent of total billed charges 50.97 78.78 Reimbursement at 85% of billed charges STAPLE SKIN REMOVAL KITS 272 RC outpatient 92.68 74.14 Aetna Commercial PPO 50.97 percent of total billed charges 50.97 78.78 55 of billed Charges BLANKET WARMING UPPER BODY 270 RC inpatient 21.16 10.58 BCBS Louisiana PPO 10.58 percent of total billed charges 10.58 17.99 50% of Eligible Charges BLANKET WARMING UPPER BODY 270 RC outpatient 21.16 16.93 BCBS Louisiana PPO 16.93 percent of total billed charges 11.64 17.99 80% of billed charge BLANKET WARMING UPPER BODY 270 RC outpatient 21.16 16.93 Cigna Commercial PPO 11.64 percent of total billed charges 11.64 17.99 55% of Billed Charges BLANKET WARMING UPPER BODY 270 RC inpatient 21.16 10.58 IMA of Louisiana Commercial PPO 17.99 percent of total billed charges 10.58 17.99 Inpatient Reimbursement at 85% of Billed Charges BLANKET WARMING UPPER BODY 270 RC outpatient 21.16 16.93 IMA of Louisiana Commercial PPO 17.99 percent of total billed charges 11.64 17.99 Reimbursement at 85% of billed charges BLANKET WARMING UPPER BODY 270 RC outpatient 21.16 16.93 Aetna Commercial PPO 11.64 percent of total billed charges 11.64 17.99 55 of billed Charges POWDER TALC 1.5OZ LF PERFM 270 RC inpatient 147.84 73.92 BCBS Louisiana PPO 73.92 percent of total billed charges 73.92 125.66 50% of Eligible Charges POWDER TALC 1.5OZ LF PERFM 270 RC outpatient 147.84 118.27 BCBS Louisiana PPO 118.27 percent of total billed charges 81.31 125.66 80% of billed charge POWDER TALC 1.5OZ LF PERFM 270 RC outpatient 147.84 118.27 Cigna Commercial PPO 81.31 percent of total billed charges 81.31 125.66 55% of Billed Charges POWDER TALC 1.5OZ LF PERFM 270 RC inpatient 147.84 73.92 IMA of Louisiana Commercial PPO 125.66 percent of total billed charges 73.92 125.66 Inpatient Reimbursement at 85% of Billed Charges POWDER TALC 1.5OZ LF PERFM 270 RC outpatient 147.84 118.27 IMA of Louisiana Commercial PPO 125.66 percent of total billed charges 81.31 125.66 Reimbursement at 85% of billed charges POWDER TALC 1.5OZ LF PERFM 270 RC outpatient 147.84 118.27 Aetna Commercial PPO 81.31 percent of total billed charges 81.31 125.66 55 of billed Charges GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC inpatient 445.63 222.82 BCBS Louisiana PPO 222.82 percent of total billed charges 222.82 378.79 50% of Eligible Charges GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC outpatient 445.63 356.5 BCBS Louisiana PPO 356.5 percent of total billed charges 245.1 378.79 80% of billed charge GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC outpatient 445.63 356.5 Cigna Commercial PPO 245.1 percent of total billed charges 245.1 378.79 55% of Billed Charges GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC inpatient 445.63 222.82 IMA of Louisiana Commercial PPO 378.79 percent of total billed charges 222.82 378.79 Inpatient Reimbursement at 85% of Billed Charges GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC outpatient 445.63 356.5 IMA of Louisiana Commercial PPO 378.79 percent of total billed charges 245.1 378.79 Reimbursement at 85% of billed charges GLOVE ANSELL RAD. ATTEN. SZ 8 - UTTER 272 RC outpatient 445.63 356.5 Aetna Commercial PPO 245.1 percent of total billed charges 245.1 378.79 55 of billed Charges DRAPE MICROSCOPE VERIOS88 272 RC inpatient 473.94 236.97 BCBS Louisiana PPO 236.97 percent of total billed charges 236.97 402.85 50% of Eligible Charges DRAPE MICROSCOPE VERIOS88 272 RC outpatient 473.94 379.15 BCBS Louisiana PPO 379.15 percent of total billed charges 260.67 402.85 80% of billed charge DRAPE MICROSCOPE VERIOS88 272 RC outpatient 473.94 379.15 Cigna Commercial PPO 260.67 percent of total billed charges 260.67 402.85 55% of Billed Charges DRAPE MICROSCOPE VERIOS88 272 RC inpatient 473.94 236.97 IMA of Louisiana Commercial PPO 402.85 percent of total billed charges 236.97 402.85 Inpatient Reimbursement at 85% of Billed Charges DRAPE MICROSCOPE VERIOS88 272 RC outpatient 473.94 379.15 IMA of Louisiana Commercial PPO 402.85 percent of total billed charges 260.67 402.85 Reimbursement at 85% of billed charges DRAPE MICROSCOPE VERIOS88 272 RC outpatient 473.94 379.15 Aetna Commercial PPO 260.67 percent of total billed charges 260.67 402.85 55 of billed Charges SHOULDER ABDUCTION PILLOW LG 270 RC inpatient 140 70 BCBS Louisiana PPO 70 percent of total billed charges 70 119 50% of Eligible Charges SHOULDER ABDUCTION PILLOW LG 270 RC outpatient 140 112 BCBS Louisiana PPO 112 percent of total billed charges 77 119 80% of billed charge SHOULDER ABDUCTION PILLOW LG 270 RC outpatient 140 112 Cigna Commercial PPO 77 percent of total billed charges 77 119 55% of Billed Charges SHOULDER ABDUCTION PILLOW LG 270 RC inpatient 140 70 IMA of Louisiana Commercial PPO 119 percent of total billed charges 70 119 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ABDUCTION PILLOW LG 270 RC outpatient 140 112 IMA of Louisiana Commercial PPO 119 percent of total billed charges 77 119 Reimbursement at 85% of billed charges SHOULDER ABDUCTION PILLOW LG 270 RC outpatient 140 112 Aetna Commercial PPO 77 percent of total billed charges 77 119 55 of billed Charges SLING ARM ENVELOPE LARGE 270 RC inpatient 24 12 BCBS Louisiana PPO 12 percent of total billed charges 12 20.4 50% of Eligible Charges SLING ARM ENVELOPE LARGE 270 RC outpatient 24 19.2 BCBS Louisiana PPO 19.2 percent of total billed charges 13.2 20.4 80% of billed charge SLING ARM ENVELOPE LARGE 270 RC outpatient 24 19.2 Cigna Commercial PPO 13.2 percent of total billed charges 13.2 20.4 55% of Billed Charges SLING ARM ENVELOPE LARGE 270 RC inpatient 24 12 IMA of Louisiana Commercial PPO 20.4 percent of total billed charges 12 20.4 Inpatient Reimbursement at 85% of Billed Charges SLING ARM ENVELOPE LARGE 270 RC outpatient 24 19.2 IMA of Louisiana Commercial PPO 20.4 percent of total billed charges 13.2 20.4 Reimbursement at 85% of billed charges SLING ARM ENVELOPE LARGE 270 RC outpatient 24 19.2 Aetna Commercial PPO 13.2 percent of total billed charges 13.2 20.4 55 of billed Charges PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 571.8 285.9 BCBS Louisiana PPO 285.9 percent of total billed charges 285.9 486.03 50% of Eligible Charges PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 571.8 457.44 BCBS Louisiana PPO 457.44 percent of total billed charges 211.57 486.03 80% of billed charge PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 571.8 457.44 Cigna Commercial PPO 331.64 percent of total billed charges 211.57 486.03 58% of Billed Charges/$500 Threshold PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 571.8 285.9 IMA of Louisiana Commercial PPO 486.03 percent of total billed charges 285.9 486.03 Inpatient Reimbursement at 85% of Billed Charges PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 571.8 457.44 IMA of Louisiana Commercial PPO 486.03 percent of total billed charges 211.57 486.03 Reimbursement at 85% of billed charges PLATE 3.5MM LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 571.8 457.44 Aetna Commercial PPO 211.57 percent of total billed charges 211.57 486.03 37% Of Billed Charges 2000 SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 WOUND VAC CANISTER 500ML - KCI 270 RC inpatient 598.61 299.31 BCBS Louisiana PPO 299.31 percent of total billed charges 299.31 508.82 50% of Eligible Charges WOUND VAC CANISTER 500ML - KCI 270 RC outpatient 598.61 478.89 BCBS Louisiana PPO 478.89 percent of total billed charges 329.24 508.82 80% of billed charge WOUND VAC CANISTER 500ML - KCI 270 RC outpatient 598.61 478.89 Cigna Commercial PPO 329.24 percent of total billed charges 329.24 508.82 55% of Billed Charges WOUND VAC CANISTER 500ML - KCI 270 RC inpatient 598.61 299.31 IMA of Louisiana Commercial PPO 508.82 percent of total billed charges 299.31 508.82 Inpatient Reimbursement at 85% of Billed Charges WOUND VAC CANISTER 500ML - KCI 270 RC outpatient 598.61 478.89 IMA of Louisiana Commercial PPO 508.82 percent of total billed charges 329.24 508.82 Reimbursement at 85% of billed charges WOUND VAC CANISTER 500ML - KCI 270 RC outpatient 598.61 478.89 Aetna Commercial PPO 329.24 percent of total billed charges 329.24 508.82 55 of billed Charges VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC inpatient 546.7 273.35 BCBS Louisiana PPO 273.35 percent of total billed charges 273.35 464.7 50% of Eligible Charges VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC outpatient 546.7 437.36 BCBS Louisiana PPO 437.36 percent of total billed charges 300.69 464.7 80% of billed charge VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC outpatient 546.7 437.36 Cigna Commercial PPO 300.69 percent of total billed charges 300.69 464.7 55% of Billed Charges VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC inpatient 546.7 273.35 IMA of Louisiana Commercial PPO 464.7 percent of total billed charges 273.35 464.7 Inpatient Reimbursement at 85% of Billed Charges VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC outpatient 546.7 437.36 IMA of Louisiana Commercial PPO 464.7 percent of total billed charges 300.69 464.7 Reimbursement at 85% of billed charges VAC GRAUFOAM BRIDGE DRESSING -KCI 272 RC outpatient 546.7 437.36 Aetna Commercial PPO 300.69 percent of total billed charges 300.69 464.7 55 of billed Charges SPONGE NEURO 3 X 3 272 RC inpatient 33.8 16.9 BCBS Louisiana PPO 16.9 percent of total billed charges 16.9 28.73 50% of Eligible Charges SPONGE NEURO 3 X 3 272 RC outpatient 33.8 27.04 BCBS Louisiana PPO 27.04 percent of total billed charges 18.59 28.73 80% of billed charge SPONGE NEURO 3 X 3 272 RC outpatient 33.8 27.04 Cigna Commercial PPO 18.59 percent of total billed charges 18.59 28.73 55% of Billed Charges SPONGE NEURO 3 X 3 272 RC inpatient 33.8 16.9 IMA of Louisiana Commercial PPO 28.73 percent of total billed charges 16.9 28.73 Inpatient Reimbursement at 85% of Billed Charges SPONGE NEURO 3 X 3 272 RC outpatient 33.8 27.04 IMA of Louisiana Commercial PPO 28.73 percent of total billed charges 18.59 28.73 Reimbursement at 85% of billed charges SPONGE NEURO 3 X 3 272 RC outpatient 33.8 27.04 Aetna Commercial PPO 18.59 percent of total billed charges 18.59 28.73 55 of billed Charges PATIENT ADMIT KITS 270 RC inpatient 45.4 22.7 BCBS Louisiana PPO 22.7 percent of total billed charges 22.7 38.59 50% of Eligible Charges PATIENT ADMIT KITS 270 RC outpatient 45.4 36.32 BCBS Louisiana PPO 36.32 percent of total billed charges 24.97 38.59 80% of billed charge PATIENT ADMIT KITS 270 RC outpatient 45.4 36.32 Cigna Commercial PPO 24.97 percent of total billed charges 24.97 38.59 55% of Billed Charges PATIENT ADMIT KITS 270 RC inpatient 45.4 22.7 IMA of Louisiana Commercial PPO 38.59 percent of total billed charges 22.7 38.59 Inpatient Reimbursement at 85% of Billed Charges PATIENT ADMIT KITS 270 RC outpatient 45.4 36.32 IMA of Louisiana Commercial PPO 38.59 percent of total billed charges 24.97 38.59 Reimbursement at 85% of billed charges PATIENT ADMIT KITS 270 RC outpatient 45.4 36.32 Aetna Commercial PPO 24.97 percent of total billed charges 24.97 38.59 55 of billed Charges MIAMI J COLLAR SMALL 270 RC inpatient 232.19 116.1 BCBS Louisiana PPO 116.1 percent of total billed charges 116.1 197.36 50% of Eligible Charges MIAMI J COLLAR SMALL 270 RC outpatient 232.19 185.75 BCBS Louisiana PPO 185.75 percent of total billed charges 127.7 197.36 80% of billed charge MIAMI J COLLAR SMALL 270 RC outpatient 232.19 185.75 Cigna Commercial PPO 127.7 percent of total billed charges 127.7 197.36 55% of Billed Charges MIAMI J COLLAR SMALL 270 RC inpatient 232.19 116.1 IMA of Louisiana Commercial PPO 197.36 percent of total billed charges 116.1 197.36 Inpatient Reimbursement at 85% of Billed Charges MIAMI J COLLAR SMALL 270 RC outpatient 232.19 185.75 IMA of Louisiana Commercial PPO 197.36 percent of total billed charges 127.7 197.36 Reimbursement at 85% of billed charges MIAMI J COLLAR SMALL 270 RC outpatient 232.19 185.75 Aetna Commercial PPO 127.7 percent of total billed charges 127.7 197.36 55 of billed Charges MIAMI J COLLAR LARGE 270 RC inpatient 186.83 93.42 BCBS Louisiana PPO 93.42 percent of total billed charges 93.42 158.81 50% of Eligible Charges MIAMI J COLLAR LARGE 270 RC outpatient 186.83 149.46 BCBS Louisiana PPO 149.46 percent of total billed charges 102.76 158.81 80% of billed charge MIAMI J COLLAR LARGE 270 RC outpatient 186.83 149.46 Cigna Commercial PPO 102.76 percent of total billed charges 102.76 158.81 55% of Billed Charges MIAMI J COLLAR LARGE 270 RC inpatient 186.83 93.42 IMA of Louisiana Commercial PPO 158.81 percent of total billed charges 93.42 158.81 Inpatient Reimbursement at 85% of Billed Charges MIAMI J COLLAR LARGE 270 RC outpatient 186.83 149.46 IMA of Louisiana Commercial PPO 158.81 percent of total billed charges 102.76 158.81 Reimbursement at 85% of billed charges MIAMI J COLLAR LARGE 270 RC outpatient 186.83 149.46 Aetna Commercial PPO 102.76 percent of total billed charges 102.76 158.81 55 of billed Charges CAST PADDING 4 NONSTERILE 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges CAST PADDING 4 NONSTERILE 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge CAST PADDING 4 NONSTERILE 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges CAST PADDING 4 NONSTERILE 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 4 NONSTERILE 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges CAST PADDING 4 NONSTERILE 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges NEEDLE SPINAL 22G X 7 272 RC inpatient 248.36 124.18 BCBS Louisiana PPO 124.18 percent of total billed charges 124.18 211.11 50% of Eligible Charges NEEDLE SPINAL 22G X 7 272 RC outpatient 248.36 198.69 BCBS Louisiana PPO 198.69 percent of total billed charges 136.6 211.11 80% of billed charge NEEDLE SPINAL 22G X 7 272 RC outpatient 248.36 198.69 Cigna Commercial PPO 136.6 percent of total billed charges 136.6 211.11 55% of Billed Charges NEEDLE SPINAL 22G X 7 272 RC inpatient 248.36 124.18 IMA of Louisiana Commercial PPO 211.11 percent of total billed charges 124.18 211.11 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 22G X 7 272 RC outpatient 248.36 198.69 IMA of Louisiana Commercial PPO 211.11 percent of total billed charges 136.6 211.11 Reimbursement at 85% of billed charges NEEDLE SPINAL 22G X 7 272 RC outpatient 248.36 198.69 Aetna Commercial PPO 136.6 percent of total billed charges 136.6 211.11 55 of billed Charges CLAVE CONNECTOR 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges CLAVE CONNECTOR 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge CLAVE CONNECTOR 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges CLAVE CONNECTOR 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges CLAVE CONNECTOR 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges CLAVE CONNECTOR 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges HIBICLENS CLEANSER 8 OZ 270 RC inpatient 520.2 260.1 BCBS Louisiana PPO 260.1 percent of total billed charges 260.1 442.17 50% of Eligible Charges HIBICLENS CLEANSER 8 OZ 270 RC outpatient 520.2 416.16 BCBS Louisiana PPO 416.16 percent of total billed charges 286.11 442.17 80% of billed charge HIBICLENS CLEANSER 8 OZ 270 RC outpatient 520.2 416.16 Cigna Commercial PPO 286.11 percent of total billed charges 286.11 442.17 55% of Billed Charges HIBICLENS CLEANSER 8 OZ 270 RC inpatient 520.2 260.1 IMA of Louisiana Commercial PPO 442.17 percent of total billed charges 260.1 442.17 Inpatient Reimbursement at 85% of Billed Charges HIBICLENS CLEANSER 8 OZ 270 RC outpatient 520.2 416.16 IMA of Louisiana Commercial PPO 442.17 percent of total billed charges 286.11 442.17 Reimbursement at 85% of billed charges HIBICLENS CLEANSER 8 OZ 270 RC outpatient 520.2 416.16 Aetna Commercial PPO 286.11 percent of total billed charges 286.11 442.17 55 of billed Charges TELFA ISLAND DRESSING 6X8 272 RC inpatient 9.58 4.79 BCBS Louisiana PPO 4.79 percent of total billed charges 4.79 8.14 50% of Eligible Charges TELFA ISLAND DRESSING 6X8 272 RC outpatient 9.58 7.66 BCBS Louisiana PPO 7.66 percent of total billed charges 5.27 8.14 80% of billed charge TELFA ISLAND DRESSING 6X8 272 RC outpatient 9.58 7.66 Cigna Commercial PPO 5.27 percent of total billed charges 5.27 8.14 55% of Billed Charges TELFA ISLAND DRESSING 6X8 272 RC inpatient 9.58 4.79 IMA of Louisiana Commercial PPO 8.14 percent of total billed charges 4.79 8.14 Inpatient Reimbursement at 85% of Billed Charges TELFA ISLAND DRESSING 6X8 272 RC outpatient 9.58 7.66 IMA of Louisiana Commercial PPO 8.14 percent of total billed charges 5.27 8.14 Reimbursement at 85% of billed charges TELFA ISLAND DRESSING 6X8 272 RC outpatient 9.58 7.66 Aetna Commercial PPO 5.27 percent of total billed charges 5.27 8.14 55 of billed Charges BUR 2.0MM ROUND K-62 272 RC inpatient 80 40 BCBS Louisiana PPO 40 percent of total billed charges 40 68 50% of Eligible Charges BUR 2.0MM ROUND K-62 272 RC outpatient 80 64 BCBS Louisiana PPO 64 percent of total billed charges 44 68 80% of billed charge BUR 2.0MM ROUND K-62 272 RC outpatient 80 64 Cigna Commercial PPO 44 percent of total billed charges 44 68 55% of Billed Charges BUR 2.0MM ROUND K-62 272 RC inpatient 80 40 IMA of Louisiana Commercial PPO 68 percent of total billed charges 40 68 Inpatient Reimbursement at 85% of Billed Charges BUR 2.0MM ROUND K-62 272 RC outpatient 80 64 IMA of Louisiana Commercial PPO 68 percent of total billed charges 44 68 Reimbursement at 85% of billed charges BUR 2.0MM ROUND K-62 272 RC outpatient 80 64 Aetna Commercial PPO 44 percent of total billed charges 44 68 55 of billed Charges IV EXTENSION K-50 MILSTEAD 272 RC inpatient 452 226 BCBS Louisiana PPO 226 percent of total billed charges 226 384.2 50% of Eligible Charges IV EXTENSION K-50 MILSTEAD 272 RC outpatient 452 361.6 BCBS Louisiana PPO 361.6 percent of total billed charges 248.6 384.2 80% of billed charge IV EXTENSION K-50 MILSTEAD 272 RC outpatient 452 361.6 Cigna Commercial PPO 248.6 percent of total billed charges 248.6 384.2 55% of Billed Charges IV EXTENSION K-50 MILSTEAD 272 RC inpatient 452 226 IMA of Louisiana Commercial PPO 384.2 percent of total billed charges 226 384.2 Inpatient Reimbursement at 85% of Billed Charges IV EXTENSION K-50 MILSTEAD 272 RC outpatient 452 361.6 IMA of Louisiana Commercial PPO 384.2 percent of total billed charges 248.6 384.2 Reimbursement at 85% of billed charges IV EXTENSION K-50 MILSTEAD 272 RC outpatient 452 361.6 Aetna Commercial PPO 248.6 percent of total billed charges 248.6 384.2 55 of billed Charges SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC inpatient 470.95 235.48 BCBS Louisiana PPO 235.48 percent of total billed charges 235.48 400.31 50% of Eligible Charges SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC outpatient 470.95 376.76 BCBS Louisiana PPO 376.76 percent of total billed charges 174.25 400.31 80% of billed charge SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Cigna Commercial PPO 273.15 percent of total billed charges 174.25 400.31 58% of Billed Charges/$500 Threshold SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC inpatient 470.95 235.48 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 235.48 400.31 Inpatient Reimbursement at 85% of Billed Charges SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC outpatient 470.95 376.76 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 174.25 400.31 Reimbursement at 85% of billed charges SCREW 7.3MM TI CANN. 16MM/85MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Aetna Commercial PPO 174.25 percent of total billed charges 174.25 400.31 37% Of Billed Charges 2000 ARTHROSCOPY DRAPE - ACURIO 272 RC inpatient 154.25 77.13 BCBS Louisiana PPO 77.13 percent of total billed charges 77.13 131.11 50% of Eligible Charges ARTHROSCOPY DRAPE - ACURIO 272 RC outpatient 154.25 123.4 BCBS Louisiana PPO 123.4 percent of total billed charges 84.84 131.11 80% of billed charge ARTHROSCOPY DRAPE - ACURIO 272 RC outpatient 154.25 123.4 Cigna Commercial PPO 84.84 percent of total billed charges 84.84 131.11 55% of Billed Charges ARTHROSCOPY DRAPE - ACURIO 272 RC inpatient 154.25 77.13 IMA of Louisiana Commercial PPO 131.11 percent of total billed charges 77.13 131.11 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY DRAPE - ACURIO 272 RC outpatient 154.25 123.4 IMA of Louisiana Commercial PPO 131.11 percent of total billed charges 84.84 131.11 Reimbursement at 85% of billed charges ARTHROSCOPY DRAPE - ACURIO 272 RC outpatient 154.25 123.4 Aetna Commercial PPO 84.84 percent of total billed charges 84.84 131.11 55 of billed Charges STERI U DRAPE 272 RC inpatient 50.48 25.24 BCBS Louisiana PPO 25.24 percent of total billed charges 25.24 42.91 50% of Eligible Charges STERI U DRAPE 272 RC outpatient 50.48 40.38 BCBS Louisiana PPO 40.38 percent of total billed charges 27.76 42.91 80% of billed charge STERI U DRAPE 272 RC outpatient 50.48 40.38 Cigna Commercial PPO 27.76 percent of total billed charges 27.76 42.91 55% of Billed Charges STERI U DRAPE 272 RC inpatient 50.48 25.24 IMA of Louisiana Commercial PPO 42.91 percent of total billed charges 25.24 42.91 Inpatient Reimbursement at 85% of Billed Charges STERI U DRAPE 272 RC outpatient 50.48 40.38 IMA of Louisiana Commercial PPO 42.91 percent of total billed charges 27.76 42.91 Reimbursement at 85% of billed charges STERI U DRAPE 272 RC outpatient 50.48 40.38 Aetna Commercial PPO 27.76 percent of total billed charges 27.76 42.91 55 of billed Charges SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC inpatient 24.86 12.43 BCBS Louisiana PPO 12.43 percent of total billed charges 12.43 21.13 50% of Eligible Charges SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC outpatient 24.86 19.89 BCBS Louisiana PPO 19.89 percent of total billed charges 13.67 21.13 80% of billed charge SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC outpatient 24.86 19.89 Cigna Commercial PPO 13.67 percent of total billed charges 13.67 21.13 55% of Billed Charges SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC inpatient 24.86 12.43 IMA of Louisiana Commercial PPO 21.13 percent of total billed charges 12.43 21.13 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC outpatient 24.86 19.89 IMA of Louisiana Commercial PPO 21.13 percent of total billed charges 13.67 21.13 Reimbursement at 85% of billed charges SUTURE 4-0 MONOCRYL PS-2 Y426H 272 RC outpatient 24.86 19.89 Aetna Commercial PPO 13.67 percent of total billed charges 13.67 21.13 55 of billed Charges DRILL BIT 2.7MM TWIST - MICRO 272 RC inpatient 91 45.5 BCBS Louisiana PPO 45.5 percent of total billed charges 45.5 77.35 50% of Eligible Charges DRILL BIT 2.7MM TWIST - MICRO 272 RC outpatient 91 72.8 BCBS Louisiana PPO 72.8 percent of total billed charges 50.05 77.35 80% of billed charge DRILL BIT 2.7MM TWIST - MICRO 272 RC outpatient 91 72.8 Cigna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55% of Billed Charges DRILL BIT 2.7MM TWIST - MICRO 272 RC inpatient 91 45.5 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 45.5 77.35 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.7MM TWIST - MICRO 272 RC outpatient 91 72.8 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 50.05 77.35 Reimbursement at 85% of billed charges DRILL BIT 2.7MM TWIST - MICRO 272 RC outpatient 91 72.8 Aetna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55 of billed Charges AIRWAY BERMAN 60MM 272 RC inpatient 42.96 21.48 BCBS Louisiana PPO 21.48 percent of total billed charges 21.48 36.52 50% of Eligible Charges AIRWAY BERMAN 60MM 272 RC outpatient 42.96 34.37 BCBS Louisiana PPO 34.37 percent of total billed charges 23.63 36.52 80% of billed charge AIRWAY BERMAN 60MM 272 RC outpatient 42.96 34.37 Cigna Commercial PPO 23.63 percent of total billed charges 23.63 36.52 55% of Billed Charges AIRWAY BERMAN 60MM 272 RC inpatient 42.96 21.48 IMA of Louisiana Commercial PPO 36.52 percent of total billed charges 21.48 36.52 Inpatient Reimbursement at 85% of Billed Charges AIRWAY BERMAN 60MM 272 RC outpatient 42.96 34.37 IMA of Louisiana Commercial PPO 36.52 percent of total billed charges 23.63 36.52 Reimbursement at 85% of billed charges AIRWAY BERMAN 60MM 272 RC outpatient 42.96 34.37 Aetna Commercial PPO 23.63 percent of total billed charges 23.63 36.52 55 of billed Charges SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 44MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 TAPE CASTING 3 RED 270 RC inpatient 93.87 46.94 BCBS Louisiana PPO 46.94 percent of total billed charges 46.94 79.79 50% of Eligible Charges TAPE CASTING 3 RED 270 RC outpatient 93.87 75.1 BCBS Louisiana PPO 75.1 percent of total billed charges 51.63 79.79 80% of billed charge TAPE CASTING 3 RED 270 RC outpatient 93.87 75.1 Cigna Commercial PPO 51.63 percent of total billed charges 51.63 79.79 55% of Billed Charges TAPE CASTING 3 RED 270 RC inpatient 93.87 46.94 IMA of Louisiana Commercial PPO 79.79 percent of total billed charges 46.94 79.79 Inpatient Reimbursement at 85% of Billed Charges TAPE CASTING 3 RED 270 RC outpatient 93.87 75.1 IMA of Louisiana Commercial PPO 79.79 percent of total billed charges 51.63 79.79 Reimbursement at 85% of billed charges TAPE CASTING 3 RED 270 RC outpatient 93.87 75.1 Aetna Commercial PPO 51.63 percent of total billed charges 51.63 79.79 55 of billed Charges SHOULDER ABDUCTION PILLOW 270 RC inpatient 140 70 BCBS Louisiana PPO 70 percent of total billed charges 70 119 50% of Eligible Charges SHOULDER ABDUCTION PILLOW 270 RC outpatient 140 112 BCBS Louisiana PPO 112 percent of total billed charges 77 119 80% of billed charge SHOULDER ABDUCTION PILLOW 270 RC outpatient 140 112 Cigna Commercial PPO 77 percent of total billed charges 77 119 55% of Billed Charges SHOULDER ABDUCTION PILLOW 270 RC inpatient 140 70 IMA of Louisiana Commercial PPO 119 percent of total billed charges 70 119 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ABDUCTION PILLOW 270 RC outpatient 140 112 IMA of Louisiana Commercial PPO 119 percent of total billed charges 77 119 Reimbursement at 85% of billed charges SHOULDER ABDUCTION PILLOW 270 RC outpatient 140 112 Aetna Commercial PPO 77 percent of total billed charges 77 119 55 of billed Charges SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC inpatient 2250 1125 BCBS Louisiana PPO 1125 percent of total billed charges 1125 1912.5 50% of Eligible Charges SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC outpatient 2250 1800 BCBS Louisiana PPO 1800 percent of total billed charges 832.5 1912.5 80% of billed charge SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC outpatient 2250 1800 Cigna Commercial PPO 1305 percent of total billed charges 832.5 1912.5 58% of Billed Charges/$500 Threshold SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC inpatient 2250 1125 IMA of Louisiana Commercial PPO 1912.5 percent of total billed charges 1125 1912.5 Inpatient Reimbursement at 85% of Billed Charges SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC outpatient 2250 1800 IMA of Louisiana Commercial PPO 1912.5 percent of total billed charges 832.5 1912.5 Reimbursement at 85% of billed charges SEMI-TENDONOSIS SZ 5 C1762 HCPCS 278 RC outpatient 2250 1800 Aetna Commercial PPO 832.5 percent of total billed charges 832.5 1912.5 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 12MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 TAPE MICROPORE PAPER 3 270 RC inpatient 20.16 10.08 BCBS Louisiana PPO 10.08 percent of total billed charges 10.08 17.14 50% of Eligible Charges TAPE MICROPORE PAPER 3 270 RC outpatient 20.16 16.13 BCBS Louisiana PPO 16.13 percent of total billed charges 11.09 17.14 80% of billed charge TAPE MICROPORE PAPER 3 270 RC outpatient 20.16 16.13 Cigna Commercial PPO 11.09 percent of total billed charges 11.09 17.14 55% of Billed Charges TAPE MICROPORE PAPER 3 270 RC inpatient 20.16 10.08 IMA of Louisiana Commercial PPO 17.14 percent of total billed charges 10.08 17.14 Inpatient Reimbursement at 85% of Billed Charges TAPE MICROPORE PAPER 3 270 RC outpatient 20.16 16.13 IMA of Louisiana Commercial PPO 17.14 percent of total billed charges 11.09 17.14 Reimbursement at 85% of billed charges TAPE MICROPORE PAPER 3 270 RC outpatient 20.16 16.13 Aetna Commercial PPO 11.09 percent of total billed charges 11.09 17.14 55 of billed Charges SENSATRAC SMALL GRANUFOAM - KCI 272 RC inpatient 796.62 398.31 BCBS Louisiana PPO 398.31 percent of total billed charges 398.31 677.13 50% of Eligible Charges SENSATRAC SMALL GRANUFOAM - KCI 272 RC outpatient 796.62 637.3 BCBS Louisiana PPO 637.3 percent of total billed charges 438.14 677.13 80% of billed charge SENSATRAC SMALL GRANUFOAM - KCI 272 RC outpatient 796.62 637.3 Cigna Commercial PPO 438.14 percent of total billed charges 438.14 677.13 55% of Billed Charges SENSATRAC SMALL GRANUFOAM - KCI 272 RC inpatient 796.62 398.31 IMA of Louisiana Commercial PPO 677.13 percent of total billed charges 398.31 677.13 Inpatient Reimbursement at 85% of Billed Charges SENSATRAC SMALL GRANUFOAM - KCI 272 RC outpatient 796.62 637.3 IMA of Louisiana Commercial PPO 677.13 percent of total billed charges 438.14 677.13 Reimbursement at 85% of billed charges SENSATRAC SMALL GRANUFOAM - KCI 272 RC outpatient 796.62 637.3 Aetna Commercial PPO 438.14 percent of total billed charges 438.14 677.13 55 of billed Charges SALEM SUMP CONNECTION TUBING 272 RC inpatient 2.76 1.38 BCBS Louisiana PPO 1.38 percent of total billed charges 1.38 2.35 50% of Eligible Charges SALEM SUMP CONNECTION TUBING 272 RC outpatient 2.76 2.21 BCBS Louisiana PPO 2.21 percent of total billed charges 1.52 2.35 80% of billed charge SALEM SUMP CONNECTION TUBING 272 RC outpatient 2.76 2.21 Cigna Commercial PPO 1.52 percent of total billed charges 1.52 2.35 55% of Billed Charges SALEM SUMP CONNECTION TUBING 272 RC inpatient 2.76 1.38 IMA of Louisiana Commercial PPO 2.35 percent of total billed charges 1.38 2.35 Inpatient Reimbursement at 85% of Billed Charges SALEM SUMP CONNECTION TUBING 272 RC outpatient 2.76 2.21 IMA of Louisiana Commercial PPO 2.35 percent of total billed charges 1.52 2.35 Reimbursement at 85% of billed charges SALEM SUMP CONNECTION TUBING 272 RC outpatient 2.76 2.21 Aetna Commercial PPO 1.52 percent of total billed charges 1.52 2.35 55 of billed Charges SUTURE 0 VICRYL CP-1 J267H 272 RC inpatient 20.88 10.44 BCBS Louisiana PPO 10.44 percent of total billed charges 10.44 17.75 50% of Eligible Charges SUTURE 0 VICRYL CP-1 J267H 272 RC outpatient 20.88 16.7 BCBS Louisiana PPO 16.7 percent of total billed charges 11.48 17.75 80% of billed charge SUTURE 0 VICRYL CP-1 J267H 272 RC outpatient 20.88 16.7 Cigna Commercial PPO 11.48 percent of total billed charges 11.48 17.75 55% of Billed Charges SUTURE 0 VICRYL CP-1 J267H 272 RC inpatient 20.88 10.44 IMA of Louisiana Commercial PPO 17.75 percent of total billed charges 10.44 17.75 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CP-1 J267H 272 RC outpatient 20.88 16.7 IMA of Louisiana Commercial PPO 17.75 percent of total billed charges 11.48 17.75 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CP-1 J267H 272 RC outpatient 20.88 16.7 Aetna Commercial PPO 11.48 percent of total billed charges 11.48 17.75 55 of billed Charges SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC inpatient 142.14 71.07 BCBS Louisiana PPO 71.07 percent of total billed charges 71.07 120.82 50% of Eligible Charges SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC outpatient 142.14 113.71 BCBS Louisiana PPO 113.71 percent of total billed charges 78.18 120.82 80% of billed charge SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC outpatient 142.14 113.71 Cigna Commercial PPO 78.18 percent of total billed charges 78.18 120.82 55% of Billed Charges SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC inpatient 142.14 71.07 IMA of Louisiana Commercial PPO 120.82 percent of total billed charges 71.07 120.82 Inpatient Reimbursement at 85% of Billed Charges SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC outpatient 142.14 113.71 IMA of Louisiana Commercial PPO 120.82 percent of total billed charges 78.18 120.82 Reimbursement at 85% of billed charges SHOULDER IMMB. PILLOW - UNI. - GOOGE 270 RC outpatient 142.14 113.71 Aetna Commercial PPO 78.18 percent of total billed charges 78.18 120.82 55 of billed Charges FLO-SEAL 5ML 272 RC inpatient 1509.37 754.69 BCBS Louisiana PPO 754.69 percent of total billed charges 754.69 1282.96 50% of Eligible Charges FLO-SEAL 5ML 272 RC outpatient 1509.37 1207.5 BCBS Louisiana PPO 1207.5 percent of total billed charges 830.15 1282.96 80% of billed charge FLO-SEAL 5ML 272 RC outpatient 1509.37 1207.5 Cigna Commercial PPO 830.15 percent of total billed charges 830.15 1282.96 55% of Billed Charges FLO-SEAL 5ML 272 RC inpatient 1509.37 754.69 IMA of Louisiana Commercial PPO 1282.96 percent of total billed charges 754.69 1282.96 Inpatient Reimbursement at 85% of Billed Charges FLO-SEAL 5ML 272 RC outpatient 1509.37 1207.5 IMA of Louisiana Commercial PPO 1282.96 percent of total billed charges 830.15 1282.96 Reimbursement at 85% of billed charges FLO-SEAL 5ML 272 RC outpatient 1509.37 1207.5 Aetna Commercial PPO 830.15 percent of total billed charges 830.15 1282.96 55 of billed Charges BELT GAIT W/SLIDE LOCK BUCKLE 270 RC inpatient 30 15 BCBS Louisiana PPO 15 percent of total billed charges 15 25.5 50% of Eligible Charges BELT GAIT W/SLIDE LOCK BUCKLE 270 RC outpatient 30 24 BCBS Louisiana PPO 24 percent of total billed charges 16.5 25.5 80% of billed charge BELT GAIT W/SLIDE LOCK BUCKLE 270 RC outpatient 30 24 Cigna Commercial PPO 16.5 percent of total billed charges 16.5 25.5 55% of Billed Charges BELT GAIT W/SLIDE LOCK BUCKLE 270 RC inpatient 30 15 IMA of Louisiana Commercial PPO 25.5 percent of total billed charges 15 25.5 Inpatient Reimbursement at 85% of Billed Charges BELT GAIT W/SLIDE LOCK BUCKLE 270 RC outpatient 30 24 IMA of Louisiana Commercial PPO 25.5 percent of total billed charges 16.5 25.5 Reimbursement at 85% of billed charges BELT GAIT W/SLIDE LOCK BUCKLE 270 RC outpatient 30 24 Aetna Commercial PPO 16.5 percent of total billed charges 16.5 25.5 55 of billed Charges CERVICAL COLLAR UNIV 270 RC inpatient 11.64 5.82 BCBS Louisiana PPO 5.82 percent of total billed charges 5.82 9.89 50% of Eligible Charges CERVICAL COLLAR UNIV 270 RC outpatient 11.64 9.31 BCBS Louisiana PPO 9.31 percent of total billed charges 6.4 9.89 80% of billed charge CERVICAL COLLAR UNIV 270 RC outpatient 11.64 9.31 Cigna Commercial PPO 6.4 percent of total billed charges 6.4 9.89 55% of Billed Charges CERVICAL COLLAR UNIV 270 RC inpatient 11.64 5.82 IMA of Louisiana Commercial PPO 9.89 percent of total billed charges 5.82 9.89 Inpatient Reimbursement at 85% of Billed Charges CERVICAL COLLAR UNIV 270 RC outpatient 11.64 9.31 IMA of Louisiana Commercial PPO 9.89 percent of total billed charges 6.4 9.89 Reimbursement at 85% of billed charges CERVICAL COLLAR UNIV 270 RC outpatient 11.64 9.31 Aetna Commercial PPO 6.4 percent of total billed charges 6.4 9.89 55 of billed Charges ABDOMINAL BINDER 3 PANEL 45-62 270 RC inpatient 26.4 13.2 BCBS Louisiana PPO 13.2 percent of total billed charges 13.2 22.44 50% of Eligible Charges ABDOMINAL BINDER 3 PANEL 45-62 270 RC outpatient 26.4 21.12 BCBS Louisiana PPO 21.12 percent of total billed charges 14.52 22.44 80% of billed charge ABDOMINAL BINDER 3 PANEL 45-62 270 RC outpatient 26.4 21.12 Cigna Commercial PPO 14.52 percent of total billed charges 14.52 22.44 55% of Billed Charges ABDOMINAL BINDER 3 PANEL 45-62 270 RC inpatient 26.4 13.2 IMA of Louisiana Commercial PPO 22.44 percent of total billed charges 13.2 22.44 Inpatient Reimbursement at 85% of Billed Charges ABDOMINAL BINDER 3 PANEL 45-62 270 RC outpatient 26.4 21.12 IMA of Louisiana Commercial PPO 22.44 percent of total billed charges 14.52 22.44 Reimbursement at 85% of billed charges ABDOMINAL BINDER 3 PANEL 45-62 270 RC outpatient 26.4 21.12 Aetna Commercial PPO 14.52 percent of total billed charges 14.52 22.44 55 of billed Charges GLOVE BIOGEL SZ 7.5 272 RC inpatient 5.89 2.95 BCBS Louisiana PPO 2.95 percent of total billed charges 2.95 5.01 50% of Eligible Charges GLOVE BIOGEL SZ 7.5 272 RC outpatient 5.89 4.71 BCBS Louisiana PPO 4.71 percent of total billed charges 3.24 5.01 80% of billed charge GLOVE BIOGEL SZ 7.5 272 RC outpatient 5.89 4.71 Cigna Commercial PPO 3.24 percent of total billed charges 3.24 5.01 55% of Billed Charges GLOVE BIOGEL SZ 7.5 272 RC inpatient 5.89 2.95 IMA of Louisiana Commercial PPO 5.01 percent of total billed charges 2.95 5.01 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 7.5 272 RC outpatient 5.89 4.71 IMA of Louisiana Commercial PPO 5.01 percent of total billed charges 3.24 5.01 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 7.5 272 RC outpatient 5.89 4.71 Aetna Commercial PPO 3.24 percent of total billed charges 3.24 5.01 55 of billed Charges SHOE POST-OP FEMALE SMALL 270 RC inpatient 29.24 14.62 BCBS Louisiana PPO 14.62 percent of total billed charges 14.62 24.85 50% of Eligible Charges SHOE POST-OP FEMALE SMALL 270 RC outpatient 29.24 23.39 BCBS Louisiana PPO 23.39 percent of total billed charges 16.08 24.85 80% of billed charge SHOE POST-OP FEMALE SMALL 270 RC outpatient 29.24 23.39 Cigna Commercial PPO 16.08 percent of total billed charges 16.08 24.85 55% of Billed Charges SHOE POST-OP FEMALE SMALL 270 RC inpatient 29.24 14.62 IMA of Louisiana Commercial PPO 24.85 percent of total billed charges 14.62 24.85 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP FEMALE SMALL 270 RC outpatient 29.24 23.39 IMA of Louisiana Commercial PPO 24.85 percent of total billed charges 16.08 24.85 Reimbursement at 85% of billed charges SHOE POST-OP FEMALE SMALL 270 RC outpatient 29.24 23.39 Aetna Commercial PPO 16.08 percent of total billed charges 16.08 24.85 55 of billed Charges PREP (CHLORAPREP) CLEAR 10.5ML 272 RC inpatient 16.61 8.31 BCBS Louisiana PPO 8.31 percent of total billed charges 8.31 14.12 50% of Eligible Charges PREP (CHLORAPREP) CLEAR 10.5ML 272 RC outpatient 16.61 13.29 BCBS Louisiana PPO 13.29 percent of total billed charges 9.14 14.12 80% of billed charge PREP (CHLORAPREP) CLEAR 10.5ML 272 RC outpatient 16.61 13.29 Cigna Commercial PPO 9.14 percent of total billed charges 9.14 14.12 55% of Billed Charges PREP (CHLORAPREP) CLEAR 10.5ML 272 RC inpatient 16.61 8.31 IMA of Louisiana Commercial PPO 14.12 percent of total billed charges 8.31 14.12 Inpatient Reimbursement at 85% of Billed Charges PREP (CHLORAPREP) CLEAR 10.5ML 272 RC outpatient 16.61 13.29 IMA of Louisiana Commercial PPO 14.12 percent of total billed charges 9.14 14.12 Reimbursement at 85% of billed charges PREP (CHLORAPREP) CLEAR 10.5ML 272 RC outpatient 16.61 13.29 Aetna Commercial PPO 9.14 percent of total billed charges 9.14 14.12 55 of billed Charges MALIS IRRIGATION BIPOLAR CORD 272 RC inpatient 560 280 BCBS Louisiana PPO 280 percent of total billed charges 280 476 50% of Eligible Charges MALIS IRRIGATION BIPOLAR CORD 272 RC outpatient 560 448 BCBS Louisiana PPO 448 percent of total billed charges 308 476 80% of billed charge MALIS IRRIGATION BIPOLAR CORD 272 RC outpatient 560 448 Cigna Commercial PPO 308 percent of total billed charges 308 476 55% of Billed Charges MALIS IRRIGATION BIPOLAR CORD 272 RC inpatient 560 280 IMA of Louisiana Commercial PPO 476 percent of total billed charges 280 476 Inpatient Reimbursement at 85% of Billed Charges MALIS IRRIGATION BIPOLAR CORD 272 RC outpatient 560 448 IMA of Louisiana Commercial PPO 476 percent of total billed charges 308 476 Reimbursement at 85% of billed charges MALIS IRRIGATION BIPOLAR CORD 272 RC outpatient 560 448 Aetna Commercial PPO 308 percent of total billed charges 308 476 55 of billed Charges BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 656.25 328.13 BCBS Louisiana PPO 328.13 percent of total billed charges 328.13 557.81 50% of Eligible Charges BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 656.25 525 BCBS Louisiana PPO 525 percent of total billed charges 242.81 557.81 80% of billed charge BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 656.25 525 Cigna Commercial PPO 380.63 percent of total billed charges 242.81 557.81 58% of Billed Charges/$500 Threshold BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 656.25 328.13 IMA of Louisiana Commercial PPO 557.81 percent of total billed charges 328.13 557.81 Inpatient Reimbursement at 85% of Billed Charges BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 656.25 525 IMA of Louisiana Commercial PPO 557.81 percent of total billed charges 242.81 557.81 Reimbursement at 85% of billed charges BONE 30CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 656.25 525 Aetna Commercial PPO 242.81 percent of total billed charges 242.81 557.81 37% Of Billed Charges 2000 SOCK SLIPPER TERRY W/TREAD 270 RC inpatient 5.33 2.67 BCBS Louisiana PPO 2.67 percent of total billed charges 2.67 4.53 50% of Eligible Charges SOCK SLIPPER TERRY W/TREAD 270 RC outpatient 5.33 4.26 BCBS Louisiana PPO 4.26 percent of total billed charges 2.93 4.53 80% of billed charge SOCK SLIPPER TERRY W/TREAD 270 RC outpatient 5.33 4.26 Cigna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55% of Billed Charges SOCK SLIPPER TERRY W/TREAD 270 RC inpatient 5.33 2.67 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.67 4.53 Inpatient Reimbursement at 85% of Billed Charges SOCK SLIPPER TERRY W/TREAD 270 RC outpatient 5.33 4.26 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.93 4.53 Reimbursement at 85% of billed charges SOCK SLIPPER TERRY W/TREAD 270 RC outpatient 5.33 4.26 Aetna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55 of billed Charges ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC inpatient 540 270 BCBS Louisiana PPO 270 percent of total billed charges 270 459 50% of Eligible Charges ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 BCBS Louisiana PPO 432 percent of total billed charges 297 459 80% of billed charge ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 Cigna Commercial PPO 297 percent of total billed charges 297 459 55% of Billed Charges ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC inpatient 540 270 IMA of Louisiana Commercial PPO 459 percent of total billed charges 270 459 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 IMA of Louisiana Commercial PPO 459 percent of total billed charges 297 459 Reimbursement at 85% of billed charges ARTHROSCOPY 5.5MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 Aetna Commercial PPO 297 percent of total billed charges 297 459 55 of billed Charges BUR AM-8 14CM #14MH30 272 RC inpatient 280.56 140.28 BCBS Louisiana PPO 140.28 percent of total billed charges 140.28 238.48 50% of Eligible Charges BUR AM-8 14CM #14MH30 272 RC outpatient 280.56 224.45 BCBS Louisiana PPO 224.45 percent of total billed charges 154.31 238.48 80% of billed charge BUR AM-8 14CM #14MH30 272 RC outpatient 280.56 224.45 Cigna Commercial PPO 154.31 percent of total billed charges 154.31 238.48 55% of Billed Charges BUR AM-8 14CM #14MH30 272 RC inpatient 280.56 140.28 IMA of Louisiana Commercial PPO 238.48 percent of total billed charges 140.28 238.48 Inpatient Reimbursement at 85% of Billed Charges BUR AM-8 14CM #14MH30 272 RC outpatient 280.56 224.45 IMA of Louisiana Commercial PPO 238.48 percent of total billed charges 154.31 238.48 Reimbursement at 85% of billed charges BUR AM-8 14CM #14MH30 272 RC outpatient 280.56 224.45 Aetna Commercial PPO 154.31 percent of total billed charges 154.31 238.48 55 of billed Charges ACCU-DISC PRESSURE SYRINGE 272 RC inpatient 363.55 181.78 BCBS Louisiana PPO 181.78 percent of total billed charges 181.78 309.02 50% of Eligible Charges ACCU-DISC PRESSURE SYRINGE 272 RC outpatient 363.55 290.84 BCBS Louisiana PPO 290.84 percent of total billed charges 199.95 309.02 80% of billed charge ACCU-DISC PRESSURE SYRINGE 272 RC outpatient 363.55 290.84 Cigna Commercial PPO 199.95 percent of total billed charges 199.95 309.02 55% of Billed Charges ACCU-DISC PRESSURE SYRINGE 272 RC inpatient 363.55 181.78 IMA of Louisiana Commercial PPO 309.02 percent of total billed charges 181.78 309.02 Inpatient Reimbursement at 85% of Billed Charges ACCU-DISC PRESSURE SYRINGE 272 RC outpatient 363.55 290.84 IMA of Louisiana Commercial PPO 309.02 percent of total billed charges 199.95 309.02 Reimbursement at 85% of billed charges ACCU-DISC PRESSURE SYRINGE 272 RC outpatient 363.55 290.84 Aetna Commercial PPO 199.95 percent of total billed charges 199.95 309.02 55 of billed Charges GUIDEWIRE 2.8 THREADED 272 RC inpatient 132.37 66.19 BCBS Louisiana PPO 66.19 percent of total billed charges 66.19 112.51 50% of Eligible Charges GUIDEWIRE 2.8 THREADED 272 RC outpatient 132.37 105.9 BCBS Louisiana PPO 105.9 percent of total billed charges 72.8 112.51 80% of billed charge GUIDEWIRE 2.8 THREADED 272 RC outpatient 132.37 105.9 Cigna Commercial PPO 72.8 percent of total billed charges 72.8 112.51 55% of Billed Charges GUIDEWIRE 2.8 THREADED 272 RC inpatient 132.37 66.19 IMA of Louisiana Commercial PPO 112.51 percent of total billed charges 66.19 112.51 Inpatient Reimbursement at 85% of Billed Charges GUIDEWIRE 2.8 THREADED 272 RC outpatient 132.37 105.9 IMA of Louisiana Commercial PPO 112.51 percent of total billed charges 72.8 112.51 Reimbursement at 85% of billed charges GUIDEWIRE 2.8 THREADED 272 RC outpatient 132.37 105.9 Aetna Commercial PPO 72.8 percent of total billed charges 72.8 112.51 55 of billed Charges DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC inpatient 91 45.5 BCBS Louisiana PPO 45.5 percent of total billed charges 45.5 77.35 50% of Eligible Charges DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC outpatient 91 72.8 BCBS Louisiana PPO 72.8 percent of total billed charges 50.05 77.35 80% of billed charge DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC outpatient 91 72.8 Cigna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55% of Billed Charges DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC inpatient 91 45.5 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 45.5 77.35 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC outpatient 91 72.8 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 50.05 77.35 Reimbursement at 85% of billed charges DRILL BIT 3.2MM 1/8 TWIST - MICRO 272 RC outpatient 91 72.8 Aetna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55 of billed Charges DRILL BIT 4.5MM TWIST - MICRO 272 RC inpatient 100 50 BCBS Louisiana PPO 50 percent of total billed charges 50 85 50% of Eligible Charges DRILL BIT 4.5MM TWIST - MICRO 272 RC outpatient 100 80 BCBS Louisiana PPO 80 percent of total billed charges 55 85 80% of billed charge DRILL BIT 4.5MM TWIST - MICRO 272 RC outpatient 100 80 Cigna Commercial PPO 55 percent of total billed charges 55 85 55% of Billed Charges DRILL BIT 4.5MM TWIST - MICRO 272 RC inpatient 100 50 IMA of Louisiana Commercial PPO 85 percent of total billed charges 50 85 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 4.5MM TWIST - MICRO 272 RC outpatient 100 80 IMA of Louisiana Commercial PPO 85 percent of total billed charges 55 85 Reimbursement at 85% of billed charges DRILL BIT 4.5MM TWIST - MICRO 272 RC outpatient 100 80 Aetna Commercial PPO 55 percent of total billed charges 55 85 55 of billed Charges SAW BLADE 2296-3-515 272 RC inpatient 101.78 50.89 BCBS Louisiana PPO 50.89 percent of total billed charges 50.89 86.51 50% of Eligible Charges SAW BLADE 2296-3-515 272 RC outpatient 101.78 81.42 BCBS Louisiana PPO 81.42 percent of total billed charges 55.98 86.51 80% of billed charge SAW BLADE 2296-3-515 272 RC outpatient 101.78 81.42 Cigna Commercial PPO 55.98 percent of total billed charges 55.98 86.51 55% of Billed Charges SAW BLADE 2296-3-515 272 RC inpatient 101.78 50.89 IMA of Louisiana Commercial PPO 86.51 percent of total billed charges 50.89 86.51 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2296-3-515 272 RC outpatient 101.78 81.42 IMA of Louisiana Commercial PPO 86.51 percent of total billed charges 55.98 86.51 Reimbursement at 85% of billed charges SAW BLADE 2296-3-515 272 RC outpatient 101.78 81.42 Aetna Commercial PPO 55.98 percent of total billed charges 55.98 86.51 55 of billed Charges AMBU BAG PEDIATRIC MASK 270 RC inpatient 286.44 143.22 BCBS Louisiana PPO 143.22 percent of total billed charges 143.22 243.47 50% of Eligible Charges AMBU BAG PEDIATRIC MASK 270 RC outpatient 286.44 229.15 BCBS Louisiana PPO 229.15 percent of total billed charges 157.54 243.47 80% of billed charge AMBU BAG PEDIATRIC MASK 270 RC outpatient 286.44 229.15 Cigna Commercial PPO 157.54 percent of total billed charges 157.54 243.47 55% of Billed Charges AMBU BAG PEDIATRIC MASK 270 RC inpatient 286.44 143.22 IMA of Louisiana Commercial PPO 243.47 percent of total billed charges 143.22 243.47 Inpatient Reimbursement at 85% of Billed Charges AMBU BAG PEDIATRIC MASK 270 RC outpatient 286.44 229.15 IMA of Louisiana Commercial PPO 243.47 percent of total billed charges 157.54 243.47 Reimbursement at 85% of billed charges AMBU BAG PEDIATRIC MASK 270 RC outpatient 286.44 229.15 Aetna Commercial PPO 157.54 percent of total billed charges 157.54 243.47 55 of billed Charges SUTURE 5-0 CHROMIC GUT P-3 272 RC inpatient 25.92 12.96 BCBS Louisiana PPO 12.96 percent of total billed charges 12.96 22.03 50% of Eligible Charges SUTURE 5-0 CHROMIC GUT P-3 272 RC outpatient 25.92 20.74 BCBS Louisiana PPO 20.74 percent of total billed charges 14.26 22.03 80% of billed charge SUTURE 5-0 CHROMIC GUT P-3 272 RC outpatient 25.92 20.74 Cigna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55% of Billed Charges SUTURE 5-0 CHROMIC GUT P-3 272 RC inpatient 25.92 12.96 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 12.96 22.03 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 CHROMIC GUT P-3 272 RC outpatient 25.92 20.74 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 14.26 22.03 Reimbursement at 85% of billed charges SUTURE 5-0 CHROMIC GUT P-3 272 RC outpatient 25.92 20.74 Aetna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55 of billed Charges GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC inpatient 507.15 253.58 BCBS Louisiana PPO 253.58 percent of total billed charges 253.58 431.08 50% of Eligible Charges GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC outpatient 507.15 405.72 BCBS Louisiana PPO 405.72 percent of total billed charges 278.93 431.08 80% of billed charge GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC outpatient 507.15 405.72 Cigna Commercial PPO 278.93 percent of total billed charges 278.93 431.08 55% of Billed Charges GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC inpatient 507.15 253.58 IMA of Louisiana Commercial PPO 431.08 percent of total billed charges 253.58 431.08 Inpatient Reimbursement at 85% of Billed Charges GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC outpatient 507.15 405.72 IMA of Louisiana Commercial PPO 431.08 percent of total billed charges 278.93 431.08 Reimbursement at 85% of billed charges GUIDEWIRE 1.6MM GOLD THREADED 5/150MM 272 RC outpatient 507.15 405.72 Aetna Commercial PPO 278.93 percent of total billed charges 278.93 431.08 55 of billed Charges CERVICAL VISUALIZATION HARNESS 270 RC inpatient 139.86 69.93 BCBS Louisiana PPO 69.93 percent of total billed charges 69.93 118.88 50% of Eligible Charges CERVICAL VISUALIZATION HARNESS 270 RC outpatient 139.86 111.89 BCBS Louisiana PPO 111.89 percent of total billed charges 76.92 118.88 80% of billed charge CERVICAL VISUALIZATION HARNESS 270 RC outpatient 139.86 111.89 Cigna Commercial PPO 76.92 percent of total billed charges 76.92 118.88 55% of Billed Charges CERVICAL VISUALIZATION HARNESS 270 RC inpatient 139.86 69.93 IMA of Louisiana Commercial PPO 118.88 percent of total billed charges 69.93 118.88 Inpatient Reimbursement at 85% of Billed Charges CERVICAL VISUALIZATION HARNESS 270 RC outpatient 139.86 111.89 IMA of Louisiana Commercial PPO 118.88 percent of total billed charges 76.92 118.88 Reimbursement at 85% of billed charges CERVICAL VISUALIZATION HARNESS 270 RC outpatient 139.86 111.89 Aetna Commercial PPO 76.92 percent of total billed charges 76.92 118.88 55 of billed Charges DERMATOME BLADE 272 RC inpatient 845.46 422.73 BCBS Louisiana PPO 422.73 percent of total billed charges 422.73 718.64 50% of Eligible Charges DERMATOME BLADE 272 RC outpatient 845.46 676.37 BCBS Louisiana PPO 676.37 percent of total billed charges 465 718.64 80% of billed charge DERMATOME BLADE 272 RC outpatient 845.46 676.37 Cigna Commercial PPO 465 percent of total billed charges 465 718.64 55% of Billed Charges DERMATOME BLADE 272 RC inpatient 845.46 422.73 IMA of Louisiana Commercial PPO 718.64 percent of total billed charges 422.73 718.64 Inpatient Reimbursement at 85% of Billed Charges DERMATOME BLADE 272 RC outpatient 845.46 676.37 IMA of Louisiana Commercial PPO 718.64 percent of total billed charges 465 718.64 Reimbursement at 85% of billed charges DERMATOME BLADE 272 RC outpatient 845.46 676.37 Aetna Commercial PPO 465 percent of total billed charges 465 718.64 55 of billed Charges DERMA SKIN CARRIER ZIMMER 272 RC inpatient 474.75 237.38 BCBS Louisiana PPO 237.38 percent of total billed charges 237.38 403.54 50% of Eligible Charges DERMA SKIN CARRIER ZIMMER 272 RC outpatient 474.75 379.8 BCBS Louisiana PPO 379.8 percent of total billed charges 261.11 403.54 80% of billed charge DERMA SKIN CARRIER ZIMMER 272 RC outpatient 474.75 379.8 Cigna Commercial PPO 261.11 percent of total billed charges 261.11 403.54 55% of Billed Charges DERMA SKIN CARRIER ZIMMER 272 RC inpatient 474.75 237.38 IMA of Louisiana Commercial PPO 403.54 percent of total billed charges 237.38 403.54 Inpatient Reimbursement at 85% of Billed Charges DERMA SKIN CARRIER ZIMMER 272 RC outpatient 474.75 379.8 IMA of Louisiana Commercial PPO 403.54 percent of total billed charges 261.11 403.54 Reimbursement at 85% of billed charges DERMA SKIN CARRIER ZIMMER 272 RC outpatient 474.75 379.8 Aetna Commercial PPO 261.11 percent of total billed charges 261.11 403.54 55 of billed Charges 25.4MM DIAMOND DISC MEDIUM 272 RC inpatient 390.78 195.39 BCBS Louisiana PPO 195.39 percent of total billed charges 195.39 332.16 50% of Eligible Charges 25.4MM DIAMOND DISC MEDIUM 272 RC outpatient 390.78 312.62 BCBS Louisiana PPO 312.62 percent of total billed charges 214.93 332.16 80% of billed charge 25.4MM DIAMOND DISC MEDIUM 272 RC outpatient 390.78 312.62 Cigna Commercial PPO 214.93 percent of total billed charges 214.93 332.16 55% of Billed Charges 25.4MM DIAMOND DISC MEDIUM 272 RC inpatient 390.78 195.39 IMA of Louisiana Commercial PPO 332.16 percent of total billed charges 195.39 332.16 Inpatient Reimbursement at 85% of Billed Charges 25.4MM DIAMOND DISC MEDIUM 272 RC outpatient 390.78 312.62 IMA of Louisiana Commercial PPO 332.16 percent of total billed charges 214.93 332.16 Reimbursement at 85% of billed charges 25.4MM DIAMOND DISC MEDIUM 272 RC outpatient 390.78 312.62 Aetna Commercial PPO 214.93 percent of total billed charges 214.93 332.16 55 of billed Charges SAW BLADE 6125-127-90 272 RC inpatient 210.88 105.44 BCBS Louisiana PPO 105.44 percent of total billed charges 105.44 179.25 50% of Eligible Charges SAW BLADE 6125-127-90 272 RC outpatient 210.88 168.7 BCBS Louisiana PPO 168.7 percent of total billed charges 115.98 179.25 80% of billed charge SAW BLADE 6125-127-90 272 RC outpatient 210.88 168.7 Cigna Commercial PPO 115.98 percent of total billed charges 115.98 179.25 55% of Billed Charges SAW BLADE 6125-127-90 272 RC inpatient 210.88 105.44 IMA of Louisiana Commercial PPO 179.25 percent of total billed charges 105.44 179.25 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 6125-127-90 272 RC outpatient 210.88 168.7 IMA of Louisiana Commercial PPO 179.25 percent of total billed charges 115.98 179.25 Reimbursement at 85% of billed charges SAW BLADE 6125-127-90 272 RC outpatient 210.88 168.7 Aetna Commercial PPO 115.98 percent of total billed charges 115.98 179.25 55 of billed Charges IV CATH 24G INTROCAN 272 RC inpatient 10.82 5.41 BCBS Louisiana PPO 5.41 percent of total billed charges 5.41 9.2 50% of Eligible Charges IV CATH 24G INTROCAN 272 RC outpatient 10.82 8.66 BCBS Louisiana PPO 8.66 percent of total billed charges 5.95 9.2 80% of billed charge IV CATH 24G INTROCAN 272 RC outpatient 10.82 8.66 Cigna Commercial PPO 5.95 percent of total billed charges 5.95 9.2 55% of Billed Charges IV CATH 24G INTROCAN 272 RC inpatient 10.82 5.41 IMA of Louisiana Commercial PPO 9.2 percent of total billed charges 5.41 9.2 Inpatient Reimbursement at 85% of Billed Charges IV CATH 24G INTROCAN 272 RC outpatient 10.82 8.66 IMA of Louisiana Commercial PPO 9.2 percent of total billed charges 5.95 9.2 Reimbursement at 85% of billed charges IV CATH 24G INTROCAN 272 RC outpatient 10.82 8.66 Aetna Commercial PPO 5.95 percent of total billed charges 5.95 9.2 55 of billed Charges SUTURE 1 PDS TP-1 Z880G 272 RC inpatient 21.48 10.74 BCBS Louisiana PPO 10.74 percent of total billed charges 10.74 18.26 50% of Eligible Charges SUTURE 1 PDS TP-1 Z880G 272 RC outpatient 21.48 17.18 BCBS Louisiana PPO 17.18 percent of total billed charges 11.81 18.26 80% of billed charge SUTURE 1 PDS TP-1 Z880G 272 RC outpatient 21.48 17.18 Cigna Commercial PPO 11.81 percent of total billed charges 11.81 18.26 55% of Billed Charges SUTURE 1 PDS TP-1 Z880G 272 RC inpatient 21.48 10.74 IMA of Louisiana Commercial PPO 18.26 percent of total billed charges 10.74 18.26 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 PDS TP-1 Z880G 272 RC outpatient 21.48 17.18 IMA of Louisiana Commercial PPO 18.26 percent of total billed charges 11.81 18.26 Reimbursement at 85% of billed charges SUTURE 1 PDS TP-1 Z880G 272 RC outpatient 21.48 17.18 Aetna Commercial PPO 11.81 percent of total billed charges 11.81 18.26 55 of billed Charges BUR #T15MH25 2.5MM 15CM 272 RC inpatient 386.75 193.38 BCBS Louisiana PPO 193.38 percent of total billed charges 193.38 328.74 50% of Eligible Charges BUR #T15MH25 2.5MM 15CM 272 RC outpatient 386.75 309.4 BCBS Louisiana PPO 309.4 percent of total billed charges 212.71 328.74 80% of billed charge BUR #T15MH25 2.5MM 15CM 272 RC outpatient 386.75 309.4 Cigna Commercial PPO 212.71 percent of total billed charges 212.71 328.74 55% of Billed Charges BUR #T15MH25 2.5MM 15CM 272 RC inpatient 386.75 193.38 IMA of Louisiana Commercial PPO 328.74 percent of total billed charges 193.38 328.74 Inpatient Reimbursement at 85% of Billed Charges BUR #T15MH25 2.5MM 15CM 272 RC outpatient 386.75 309.4 IMA of Louisiana Commercial PPO 328.74 percent of total billed charges 212.71 328.74 Reimbursement at 85% of billed charges BUR #T15MH25 2.5MM 15CM 272 RC outpatient 386.75 309.4 Aetna Commercial PPO 212.71 percent of total billed charges 212.71 328.74 55 of billed Charges SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC inpatient 107.66 53.83 BCBS Louisiana PPO 53.83 percent of total billed charges 53.83 91.51 50% of Eligible Charges SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC outpatient 107.66 86.13 BCBS Louisiana PPO 86.13 percent of total billed charges 39.83 91.51 80% of billed charge SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC outpatient 107.66 86.13 Cigna Commercial PPO 62.44 percent of total billed charges 39.83 91.51 58% of Billed Charges/$500 Threshold SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC inpatient 107.66 53.83 IMA of Louisiana Commercial PPO 91.51 percent of total billed charges 53.83 91.51 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC outpatient 107.66 86.13 IMA of Louisiana Commercial PPO 91.51 percent of total billed charges 39.83 91.51 Reimbursement at 85% of billed charges SCREW 2.7MM SELF-TAP CORTEX 20MM C1713 HCPCS 278 RC outpatient 107.66 86.13 Aetna Commercial PPO 39.83 percent of total billed charges 39.83 91.51 37% Of Billed Charges 2000 ABDUCTION HIP PILLOW - MEDIUM 270 RC inpatient 82 41 BCBS Louisiana PPO 41 percent of total billed charges 41 69.7 50% of Eligible Charges ABDUCTION HIP PILLOW - MEDIUM 270 RC outpatient 82 65.6 BCBS Louisiana PPO 65.6 percent of total billed charges 45.1 69.7 80% of billed charge ABDUCTION HIP PILLOW - MEDIUM 270 RC outpatient 82 65.6 Cigna Commercial PPO 45.1 percent of total billed charges 45.1 69.7 55% of Billed Charges ABDUCTION HIP PILLOW - MEDIUM 270 RC inpatient 82 41 IMA of Louisiana Commercial PPO 69.7 percent of total billed charges 41 69.7 Inpatient Reimbursement at 85% of Billed Charges ABDUCTION HIP PILLOW - MEDIUM 270 RC outpatient 82 65.6 IMA of Louisiana Commercial PPO 69.7 percent of total billed charges 45.1 69.7 Reimbursement at 85% of billed charges ABDUCTION HIP PILLOW - MEDIUM 270 RC outpatient 82 65.6 Aetna Commercial PPO 45.1 percent of total billed charges 45.1 69.7 55 of billed Charges WALKER BARIATRIC FLDNG 500LB 270 RC inpatient 287.11 143.56 BCBS Louisiana PPO 143.56 percent of total billed charges 143.56 244.04 50% of Eligible Charges WALKER BARIATRIC FLDNG 500LB 270 RC outpatient 287.11 229.69 BCBS Louisiana PPO 229.69 percent of total billed charges 157.91 244.04 80% of billed charge WALKER BARIATRIC FLDNG 500LB 270 RC outpatient 287.11 229.69 Cigna Commercial PPO 157.91 percent of total billed charges 157.91 244.04 55% of Billed Charges WALKER BARIATRIC FLDNG 500LB 270 RC inpatient 287.11 143.56 IMA of Louisiana Commercial PPO 244.04 percent of total billed charges 143.56 244.04 Inpatient Reimbursement at 85% of Billed Charges WALKER BARIATRIC FLDNG 500LB 270 RC outpatient 287.11 229.69 IMA of Louisiana Commercial PPO 244.04 percent of total billed charges 157.91 244.04 Reimbursement at 85% of billed charges WALKER BARIATRIC FLDNG 500LB 270 RC outpatient 287.11 229.69 Aetna Commercial PPO 157.91 percent of total billed charges 157.91 244.04 55 of billed Charges DEODORANT ROLL-ON 1.5 OZ 271 RC inpatient 241.92 120.96 BCBS Louisiana PPO 120.96 percent of total billed charges 120.96 205.63 50% of Eligible Charges DEODORANT ROLL-ON 1.5 OZ 271 RC outpatient 241.92 193.54 BCBS Louisiana PPO 193.54 percent of total billed charges 133.06 205.63 80% of billed charge DEODORANT ROLL-ON 1.5 OZ 271 RC outpatient 241.92 193.54 Cigna Commercial PPO 133.06 percent of total billed charges 133.06 205.63 55% of Billed Charges DEODORANT ROLL-ON 1.5 OZ 271 RC inpatient 241.92 120.96 IMA of Louisiana Commercial PPO 205.63 percent of total billed charges 120.96 205.63 Inpatient Reimbursement at 85% of Billed Charges DEODORANT ROLL-ON 1.5 OZ 271 RC outpatient 241.92 193.54 IMA of Louisiana Commercial PPO 205.63 percent of total billed charges 133.06 205.63 Reimbursement at 85% of billed charges DEODORANT ROLL-ON 1.5 OZ 271 RC outpatient 241.92 193.54 Aetna Commercial PPO 133.06 percent of total billed charges 133.06 205.63 55 of billed Charges CENTRAL LINE KIT ANES.DR.S 272 RC inpatient 453.44 226.72 BCBS Louisiana PPO 226.72 percent of total billed charges 226.72 385.42 50% of Eligible Charges CENTRAL LINE KIT ANES.DR.S 272 RC outpatient 453.44 362.75 BCBS Louisiana PPO 362.75 percent of total billed charges 249.39 385.42 80% of billed charge CENTRAL LINE KIT ANES.DR.S 272 RC outpatient 453.44 362.75 Cigna Commercial PPO 249.39 percent of total billed charges 249.39 385.42 55% of Billed Charges CENTRAL LINE KIT ANES.DR.S 272 RC inpatient 453.44 226.72 IMA of Louisiana Commercial PPO 385.42 percent of total billed charges 226.72 385.42 Inpatient Reimbursement at 85% of Billed Charges CENTRAL LINE KIT ANES.DR.S 272 RC outpatient 453.44 362.75 IMA of Louisiana Commercial PPO 385.42 percent of total billed charges 249.39 385.42 Reimbursement at 85% of billed charges CENTRAL LINE KIT ANES.DR.S 272 RC outpatient 453.44 362.75 Aetna Commercial PPO 249.39 percent of total billed charges 249.39 385.42 55 of billed Charges WASHER 10MM--SYNTHES L8699 HCPCS 278 RC inpatient 88.16 44.08 BCBS Louisiana PPO 44.08 percent of total billed charges 44.08 74.94 50% of Eligible Charges WASHER 10MM--SYNTHES L8699 HCPCS 278 RC outpatient 88.16 70.53 BCBS Louisiana PPO 70.53 percent of total billed charges 32.62 74.94 80% of billed charge WASHER 10MM--SYNTHES L8699 HCPCS 278 RC outpatient 88.16 70.53 Cigna Commercial PPO 51.13 percent of total billed charges 32.62 74.94 58% of Billed Charges/$500 Threshold WASHER 10MM--SYNTHES L8699 HCPCS 278 RC inpatient 88.16 44.08 IMA of Louisiana Commercial PPO 74.94 percent of total billed charges 44.08 74.94 Inpatient Reimbursement at 85% of Billed Charges WASHER 10MM--SYNTHES L8699 HCPCS 278 RC outpatient 88.16 70.53 IMA of Louisiana Commercial PPO 74.94 percent of total billed charges 32.62 74.94 Reimbursement at 85% of billed charges WASHER 10MM--SYNTHES L8699 HCPCS 278 RC outpatient 88.16 70.53 Aetna Commercial PPO 32.62 percent of total billed charges 32.62 74.94 37% Of Billed Charges 2000 CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC inpatient 44.64 22.32 BCBS Louisiana PPO 22.32 percent of total billed charges 22.32 37.94 50% of Eligible Charges CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC outpatient 44.64 35.71 BCBS Louisiana PPO 35.71 percent of total billed charges 24.55 37.94 80% of billed charge CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC outpatient 44.64 35.71 Cigna Commercial PPO 24.55 percent of total billed charges 24.55 37.94 55% of Billed Charges CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC inpatient 44.64 22.32 IMA of Louisiana Commercial PPO 37.94 percent of total billed charges 22.32 37.94 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC outpatient 44.64 35.71 IMA of Louisiana Commercial PPO 37.94 percent of total billed charges 24.55 37.94 Reimbursement at 85% of billed charges CATHETER COUDE LTX/TEF 14FR 5CC - GU DR 272 RC outpatient 44.64 35.71 Aetna Commercial PPO 24.55 percent of total billed charges 24.55 37.94 55 of billed Charges WATER STR IRR SOL 250ML 272 RC inpatient 7.07 3.54 BCBS Louisiana PPO 3.54 percent of total billed charges 3.54 6.01 50% of Eligible Charges WATER STR IRR SOL 250ML 272 RC outpatient 7.07 5.66 BCBS Louisiana PPO 5.66 percent of total billed charges 3.89 6.01 80% of billed charge WATER STR IRR SOL 250ML 272 RC outpatient 7.07 5.66 Cigna Commercial PPO 3.89 percent of total billed charges 3.89 6.01 55% of Billed Charges WATER STR IRR SOL 250ML 272 RC inpatient 7.07 3.54 IMA of Louisiana Commercial PPO 6.01 percent of total billed charges 3.54 6.01 Inpatient Reimbursement at 85% of Billed Charges WATER STR IRR SOL 250ML 272 RC outpatient 7.07 5.66 IMA of Louisiana Commercial PPO 6.01 percent of total billed charges 3.89 6.01 Reimbursement at 85% of billed charges WATER STR IRR SOL 250ML 272 RC outpatient 7.07 5.66 Aetna Commercial PPO 3.89 percent of total billed charges 3.89 6.01 55 of billed Charges BUR #MC30 3MM CARBIDE 272 RC inpatient 546 273 BCBS Louisiana PPO 273 percent of total billed charges 273 464.1 50% of Eligible Charges BUR #MC30 3MM CARBIDE 272 RC outpatient 546 436.8 BCBS Louisiana PPO 436.8 percent of total billed charges 300.3 464.1 80% of billed charge BUR #MC30 3MM CARBIDE 272 RC outpatient 546 436.8 Cigna Commercial PPO 300.3 percent of total billed charges 300.3 464.1 55% of Billed Charges BUR #MC30 3MM CARBIDE 272 RC inpatient 546 273 IMA of Louisiana Commercial PPO 464.1 percent of total billed charges 273 464.1 Inpatient Reimbursement at 85% of Billed Charges BUR #MC30 3MM CARBIDE 272 RC outpatient 546 436.8 IMA of Louisiana Commercial PPO 464.1 percent of total billed charges 300.3 464.1 Reimbursement at 85% of billed charges BUR #MC30 3MM CARBIDE 272 RC outpatient 546 436.8 Aetna Commercial PPO 300.3 percent of total billed charges 300.3 464.1 55 of billed Charges IMMOBILIZER UNIVERSAL KNEE 24 270 RC inpatient 73.16 36.58 BCBS Louisiana PPO 36.58 percent of total billed charges 36.58 62.19 50% of Eligible Charges IMMOBILIZER UNIVERSAL KNEE 24 270 RC outpatient 73.16 58.53 BCBS Louisiana PPO 58.53 percent of total billed charges 40.24 62.19 80% of billed charge IMMOBILIZER UNIVERSAL KNEE 24 270 RC outpatient 73.16 58.53 Cigna Commercial PPO 40.24 percent of total billed charges 40.24 62.19 55% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 24 270 RC inpatient 73.16 36.58 IMA of Louisiana Commercial PPO 62.19 percent of total billed charges 36.58 62.19 Inpatient Reimbursement at 85% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 24 270 RC outpatient 73.16 58.53 IMA of Louisiana Commercial PPO 62.19 percent of total billed charges 40.24 62.19 Reimbursement at 85% of billed charges IMMOBILIZER UNIVERSAL KNEE 24 270 RC outpatient 73.16 58.53 Aetna Commercial PPO 40.24 percent of total billed charges 40.24 62.19 55 of billed Charges OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC inpatient 10625 5312.5 BCBS Louisiana PPO 5312.5 percent of total billed charges 5312.5 9031.25 50% of Eligible Charges OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC outpatient 10625 8500 BCBS Louisiana PPO 8500 percent of total billed charges 100 9031.25 80% of billed charges OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC outpatient 10625 8500 Cigna Commercial PPO 100 fee schedule 100 9031.25 Paid case rate based off grouper OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC inpatient 10625 5312.5 IMA of Louisiana Commercial PPO 9031.25 percent of total billed charges 5312.5 9031.25 Inpatient Reimbursement at 85% of Billed Charges OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC outpatient 10625 8500 IMA of Louisiana Commercial PPO 9031.25 percent of total billed charges 100 9031.25 Reimbursement at 85% of billed charges OSTEOCHONDRAL KNEE ALLOGRAFT 27415 CPT 360 RC outpatient 10625 8500 Aetna Commercial PPO 1300 fee schedule 100 9031.25 Case Rate FIXATION OF KNEE JOINT 27570 CPT 360 RC inpatient 3172.35 1586.18 BCBS Louisiana PPO 1586.18 percent of total billed charges 1586.18 2696.5 50% of Eligible Charges FIXATION OF KNEE JOINT 27570 CPT 360 RC outpatient 3172.35 2537.88 BCBS Louisiana PPO 2537.88 percent of total billed charges 1300 2696.5 80% of billed charges FIXATION OF KNEE JOINT 27570 CPT 360 RC outpatient 3172.35 2537.88 Cigna Commercial PPO 1744.79 percent of total billed charges 1300 2696.5 55% of Billed Charges FIXATION OF KNEE JOINT 27570 CPT 360 RC inpatient 3172.35 1586.18 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1586.18 2696.5 Inpatient Reimbursement at 85% of Billed Charges FIXATION OF KNEE JOINT 27570 CPT 360 RC outpatient 3172.35 2537.88 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1300 2696.5 Reimbursement at 85% of billed charges FIXATION OF KNEE JOINT 27570 CPT 360 RC outpatient 3172.35 2537.88 Aetna Commercial PPO 1300 fee schedule 1300 2696.5 Case Rate CYSTOURETHROSCOPY 52000 CPT 360 RC inpatient 1414 707 BCBS Louisiana PPO 707 percent of total billed charges 707 1201.9 50% of Eligible Charges CYSTOURETHROSCOPY 52000 CPT 360 RC outpatient 1414 1131.2 BCBS Louisiana PPO 1131.2 percent of total billed charges 777.7 1300 80% of billed charges CYSTOURETHROSCOPY 52000 CPT 360 RC outpatient 1414 1131.2 Cigna Commercial PPO 777.7 percent of total billed charges 777.7 1300 55% of Billed Charges CYSTOURETHROSCOPY 52000 CPT 360 RC inpatient 1414 707 IMA of Louisiana Commercial PPO 1201.9 percent of total billed charges 707 1201.9 Inpatient Reimbursement at 85% of Billed Charges CYSTOURETHROSCOPY 52000 CPT 360 RC outpatient 1414 1131.2 IMA of Louisiana Commercial PPO 1201.9 percent of total billed charges 777.7 1300 Reimbursement at 85% of billed charges CYSTOURETHROSCOPY 52000 CPT 360 RC outpatient 1414 1131.2 Aetna Commercial PPO 1300 fee schedule 777.7 1300 Case Rate SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC inpatient 3921.08 1960.54 BCBS Louisiana PPO 1960.54 percent of total billed charges 1960.54 3332.92 50% of Eligible Charges SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC outpatient 3921.08 3136.86 BCBS Louisiana PPO 3136.86 percent of total billed charges 1300 3332.92 80% of billed charges SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC outpatient 3921.08 3136.86 Cigna Commercial PPO 2156.59 percent of total billed charges 1300 3332.92 55% of Billed Charges SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC inpatient 3921.08 1960.54 IMA of Louisiana Commercial PPO 3332.92 percent of total billed charges 1960.54 3332.92 Inpatient Reimbursement at 85% of Billed Charges SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC outpatient 3921.08 3136.86 IMA of Louisiana Commercial PPO 3332.92 percent of total billed charges 1300 3332.92 Reimbursement at 85% of billed charges SKIN SUB GRAFT TRNK/ARM/LEG 15271 CPT 360 RC outpatient 3921.08 3136.86 Aetna Commercial PPO 1300 fee schedule 1300 3332.92 Case Rate IONM IN OR PER HOUR 95941 CPT 360 RC inpatient 477.3 238.65 BCBS Louisiana PPO 238.65 percent of total billed charges 238.65 405.71 50% of Eligible Charges IONM IN OR PER HOUR 95941 CPT 360 RC outpatient 477.3 381.84 BCBS Louisiana PPO 381.84 percent of total billed charges 262.52 405.71 80% of billed charge IONM IN OR PER HOUR 95941 CPT 360 RC outpatient 477.3 381.84 Cigna Commercial PPO 262.52 percent of total billed charges 262.52 405.71 55% of Billed Charges IONM IN OR PER HOUR 95941 CPT 360 RC inpatient 477.3 238.65 IMA of Louisiana Commercial PPO 405.71 percent of total billed charges 238.65 405.71 Inpatient Reimbursement at 85% of Billed Charges IONM IN OR PER HOUR 95941 CPT 360 RC outpatient 477.3 381.84 IMA of Louisiana Commercial PPO 405.71 percent of total billed charges 262.52 405.71 Reimbursement at 85% of billed charges IONM IN OR PER HOUR 95941 CPT 360 RC outpatient 477.3 381.84 Aetna Commercial PPO 262.52 percent of total billed charges 262.52 405.71 55 of billed Charges PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" inpatient 39.95 19.98 BCBS Louisiana PPO 19.98 percent of total billed charges 19.98 33.96 50% of Eligible Charges PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" outpatient 39.95 31.96 BCBS Louisiana PPO 31.96 percent of total billed charges 31.96 85 80% of billed charge PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" outpatient 39.95 31.96 Cigna Commercial PPO 85 other 31.96 85 63% of Billed Charges PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" inpatient 39.95 19.98 IMA of Louisiana Commercial PPO 33.96 percent of total billed charges 19.98 33.96 Inpatient Reimbursement at 85% of Billed Charges PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" outpatient 39.95 31.96 IMA of Louisiana Commercial PPO 33.96 percent of total billed charges 31.96 85 Reimbursement at 85% of billed charges PT VASOPNEUMATIC 97016 CPT 421 RC "GP,59" outpatient 39.95 31.96 Aetna Commercial PPO 35.98 fee schedule 31.96 85 200% Of Aetna Market Fee Schedule PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP inpatient 211.98 105.99 BCBS Louisiana PPO 105.99 percent of total billed charges 105.99 180.18 50% of Eligible Charges PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP outpatient 211.98 169.58 BCBS Louisiana PPO 169.58 percent of total billed charges 85 180.18 80% of billed charge PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP outpatient 211.98 169.58 Cigna Commercial PPO 85 other 85 180.18 63% of Billed Charges PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP inpatient 211.98 105.99 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 105.99 180.18 Inpatient Reimbursement at 85% of Billed Charges PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP outpatient 211.98 169.58 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 85 180.18 Reimbursement at 85% of billed charges PT EVAL HI COMPLEX 45 MIN 97163 CPT 424 RC GP outpatient 211.98 169.58 Aetna Commercial PPO 158.42 fee schedule 85 180.18 200% Of Aetna Market Fee Schedule WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC inpatient 777 388.5 BCBS Louisiana PPO 388.5 percent of total billed charges 388.5 660.45 50% of Eligible Charges WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC outpatient 777 621.6 BCBS Louisiana PPO 621.6 percent of total billed charges 427.35 660.45 80% of billed charge WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC outpatient 777 621.6 Cigna Commercial PPO 427.35 percent of total billed charges 427.35 660.45 55% of Billed Charges WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC inpatient 777 388.5 IMA of Louisiana Commercial PPO 660.45 percent of total billed charges 388.5 660.45 Inpatient Reimbursement at 85% of Billed Charges WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC outpatient 777 621.6 IMA of Louisiana Commercial PPO 660.45 percent of total billed charges 427.35 660.45 Reimbursement at 85% of billed charges WOUND VAC PLACEMENT - GREATER THAN 50CM 97606 CPT 360 RC outpatient 777 621.6 Aetna Commercial PPO 427.35 percent of total billed charges 427.35 660.45 55 of billed Charges SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 BCBS Louisiana PPO 57.44 percent of total billed charges 57.44 97.64 50% of Eligible Charges SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 BCBS Louisiana PPO 91.9 percent of total billed charges 42.5 97.64 80% of billed charge SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Cigna Commercial PPO 66.62 percent of total billed charges 42.5 97.64 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 57.44 97.64 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 42.5 97.64 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Aetna Commercial PPO 42.5 percent of total billed charges 42.5 97.64 37% Of Billed Charges 2000 DRILL BIT 2.0MM - SYNTHES 272 RC inpatient 233.59 116.8 BCBS Louisiana PPO 116.8 percent of total billed charges 116.8 198.55 50% of Eligible Charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 233.59 186.87 BCBS Louisiana PPO 186.87 percent of total billed charges 128.47 198.55 80% of billed charge DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 233.59 186.87 Cigna Commercial PPO 128.47 percent of total billed charges 128.47 198.55 55% of Billed Charges DRILL BIT 2.0MM - SYNTHES 272 RC inpatient 233.59 116.8 IMA of Louisiana Commercial PPO 198.55 percent of total billed charges 116.8 198.55 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 233.59 186.87 IMA of Louisiana Commercial PPO 198.55 percent of total billed charges 128.47 198.55 Reimbursement at 85% of billed charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 233.59 186.87 Aetna Commercial PPO 128.47 percent of total billed charges 128.47 198.55 55 of billed Charges PVP - 1 SOLUTION 270 RC inpatient 77.68 38.84 BCBS Louisiana PPO 38.84 percent of total billed charges 38.84 66.03 50% of Eligible Charges PVP - 1 SOLUTION 270 RC outpatient 77.68 62.14 BCBS Louisiana PPO 62.14 percent of total billed charges 42.72 66.03 80% of billed charge PVP - 1 SOLUTION 270 RC outpatient 77.68 62.14 Cigna Commercial PPO 42.72 percent of total billed charges 42.72 66.03 55% of Billed Charges PVP - 1 SOLUTION 270 RC inpatient 77.68 38.84 IMA of Louisiana Commercial PPO 66.03 percent of total billed charges 38.84 66.03 Inpatient Reimbursement at 85% of Billed Charges PVP - 1 SOLUTION 270 RC outpatient 77.68 62.14 IMA of Louisiana Commercial PPO 66.03 percent of total billed charges 42.72 66.03 Reimbursement at 85% of billed charges PVP - 1 SOLUTION 270 RC outpatient 77.68 62.14 Aetna Commercial PPO 42.72 percent of total billed charges 42.72 66.03 55 of billed Charges KNEE BRACE BLEDSO 28 270 RC inpatient 371.25 185.63 BCBS Louisiana PPO 185.63 percent of total billed charges 185.63 315.56 50% of Eligible Charges KNEE BRACE BLEDSO 28 270 RC outpatient 371.25 297 BCBS Louisiana PPO 297 percent of total billed charges 204.19 315.56 80% of billed charge KNEE BRACE BLEDSO 28 270 RC outpatient 371.25 297 Cigna Commercial PPO 204.19 percent of total billed charges 204.19 315.56 55% of Billed Charges KNEE BRACE BLEDSO 28 270 RC inpatient 371.25 185.63 IMA of Louisiana Commercial PPO 315.56 percent of total billed charges 185.63 315.56 Inpatient Reimbursement at 85% of Billed Charges KNEE BRACE BLEDSO 28 270 RC outpatient 371.25 297 IMA of Louisiana Commercial PPO 315.56 percent of total billed charges 204.19 315.56 Reimbursement at 85% of billed charges KNEE BRACE BLEDSO 28 270 RC outpatient 371.25 297 Aetna Commercial PPO 204.19 percent of total billed charges 204.19 315.56 55 of billed Charges SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC inpatient 115.71 57.86 BCBS Louisiana PPO 57.86 percent of total billed charges 57.86 98.35 50% of Eligible Charges SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 BCBS Louisiana PPO 92.57 percent of total billed charges 42.81 98.35 80% of billed charge SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 Cigna Commercial PPO 67.11 percent of total billed charges 42.81 98.35 58% of Billed Charges/$500 Threshold SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC inpatient 115.71 57.86 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 57.86 98.35 Inpatient Reimbursement at 85% of Billed Charges SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 42.81 98.35 Reimbursement at 85% of billed charges SCREW 6.5MM CANC. 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 Aetna Commercial PPO 42.81 percent of total billed charges 42.81 98.35 37% Of Billed Charges 2000 SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC inpatient 528.6 264.3 BCBS Louisiana PPO 264.3 percent of total billed charges 264.3 449.31 50% of Eligible Charges SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC outpatient 528.6 422.88 BCBS Louisiana PPO 422.88 percent of total billed charges 290.73 449.31 80% of billed charge SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC outpatient 528.6 422.88 Cigna Commercial PPO 290.73 percent of total billed charges 290.73 449.31 55% of Billed Charges SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC inpatient 528.6 264.3 IMA of Louisiana Commercial PPO 449.31 percent of total billed charges 264.3 449.31 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC outpatient 528.6 422.88 IMA of Louisiana Commercial PPO 449.31 percent of total billed charges 290.73 449.31 Reimbursement at 85% of billed charges SUTURE STRATAFIX #SXPD2B408 0 PDO 272 RC outpatient 528.6 422.88 Aetna Commercial PPO 290.73 percent of total billed charges 290.73 449.31 55 of billed Charges SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC inpatient 528 264 BCBS Louisiana PPO 264 percent of total billed charges 264 448.8 50% of Eligible Charges SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC outpatient 528 422.4 BCBS Louisiana PPO 422.4 percent of total billed charges 290.4 448.8 80% of billed charge SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC outpatient 528 422.4 Cigna Commercial PPO 290.4 percent of total billed charges 290.4 448.8 55% of Billed Charges SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC inpatient 528 264 IMA of Louisiana Commercial PPO 448.8 percent of total billed charges 264 448.8 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC outpatient 528 422.4 IMA of Louisiana Commercial PPO 448.8 percent of total billed charges 290.4 448.8 Reimbursement at 85% of billed charges SUTURE FIBERWIRE 3-0 AR-7227-01 272 RC outpatient 528 422.4 Aetna Commercial PPO 290.4 percent of total billed charges 290.4 448.8 55 of billed Charges SAW BLADE 6221-137-090 272 RC inpatient 184.42 92.21 BCBS Louisiana PPO 92.21 percent of total billed charges 92.21 156.76 50% of Eligible Charges SAW BLADE 6221-137-090 272 RC outpatient 184.42 147.54 BCBS Louisiana PPO 147.54 percent of total billed charges 101.43 156.76 80% of billed charge SAW BLADE 6221-137-090 272 RC outpatient 184.42 147.54 Cigna Commercial PPO 101.43 percent of total billed charges 101.43 156.76 55% of Billed Charges SAW BLADE 6221-137-090 272 RC inpatient 184.42 92.21 IMA of Louisiana Commercial PPO 156.76 percent of total billed charges 92.21 156.76 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 6221-137-090 272 RC outpatient 184.42 147.54 IMA of Louisiana Commercial PPO 156.76 percent of total billed charges 101.43 156.76 Reimbursement at 85% of billed charges SAW BLADE 6221-137-090 272 RC outpatient 184.42 147.54 Aetna Commercial PPO 101.43 percent of total billed charges 101.43 156.76 55 of billed Charges SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC inpatient 750 375 BCBS Louisiana PPO 375 percent of total billed charges 375 637.5 50% of Eligible Charges SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC outpatient 750 600 BCBS Louisiana PPO 600 percent of total billed charges 277.5 637.5 80% of billed charge SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC outpatient 750 600 Cigna Commercial PPO 435 percent of total billed charges 277.5 637.5 58% of Billed Charges/$500 Threshold SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC inpatient 750 375 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 375 637.5 Inpatient Reimbursement at 85% of Billed Charges SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC outpatient 750 600 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 277.5 637.5 Reimbursement at 85% of billed charges SCREW 1.2MM TI EMERGENCY 400.611 C1713 HCPCS 278 RC outpatient 750 600 Aetna Commercial PPO 277.5 percent of total billed charges 277.5 637.5 37% Of Billed Charges 2000 DRESSING ALLEVY LIFE 272 RC inpatient 21.22 10.61 BCBS Louisiana PPO 10.61 percent of total billed charges 10.61 18.04 50% of Eligible Charges DRESSING ALLEVY LIFE 272 RC outpatient 21.22 16.98 BCBS Louisiana PPO 16.98 percent of total billed charges 11.67 18.04 80% of billed charge DRESSING ALLEVY LIFE 272 RC outpatient 21.22 16.98 Cigna Commercial PPO 11.67 percent of total billed charges 11.67 18.04 55% of Billed Charges DRESSING ALLEVY LIFE 272 RC inpatient 21.22 10.61 IMA of Louisiana Commercial PPO 18.04 percent of total billed charges 10.61 18.04 Inpatient Reimbursement at 85% of Billed Charges DRESSING ALLEVY LIFE 272 RC outpatient 21.22 16.98 IMA of Louisiana Commercial PPO 18.04 percent of total billed charges 11.67 18.04 Reimbursement at 85% of billed charges DRESSING ALLEVY LIFE 272 RC outpatient 21.22 16.98 Aetna Commercial PPO 11.67 percent of total billed charges 11.67 18.04 55 of billed Charges DRAIN 7FR ROUND 272 RC inpatient 474.96 237.48 BCBS Louisiana PPO 237.48 percent of total billed charges 237.48 403.72 50% of Eligible Charges DRAIN 7FR ROUND 272 RC outpatient 474.96 379.97 BCBS Louisiana PPO 379.97 percent of total billed charges 261.23 403.72 80% of billed charge DRAIN 7FR ROUND 272 RC outpatient 474.96 379.97 Cigna Commercial PPO 261.23 percent of total billed charges 261.23 403.72 55% of Billed Charges DRAIN 7FR ROUND 272 RC inpatient 474.96 237.48 IMA of Louisiana Commercial PPO 403.72 percent of total billed charges 237.48 403.72 Inpatient Reimbursement at 85% of Billed Charges DRAIN 7FR ROUND 272 RC outpatient 474.96 379.97 IMA of Louisiana Commercial PPO 403.72 percent of total billed charges 261.23 403.72 Reimbursement at 85% of billed charges DRAIN 7FR ROUND 272 RC outpatient 474.96 379.97 Aetna Commercial PPO 261.23 percent of total billed charges 261.23 403.72 55 of billed Charges ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC inpatient 595 297.5 BCBS Louisiana PPO 297.5 percent of total billed charges 297.5 505.75 50% of Eligible Charges ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC outpatient 595 476 BCBS Louisiana PPO 476 percent of total billed charges 220.15 505.75 80% of billed charge ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC outpatient 595 476 Cigna Commercial PPO 345.1 percent of total billed charges 220.15 505.75 58% of Billed Charges/$500 Threshold ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC inpatient 595 297.5 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 297.5 505.75 Inpatient Reimbursement at 85% of Billed Charges ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC outpatient 595 476 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 220.15 505.75 Reimbursement at 85% of billed charges ANCHOR HEALICOIL 5.5MM #72203380 - S&N E C1713 HCPCS 278 RC outpatient 595 476 Aetna Commercial PPO 220.15 percent of total billed charges 220.15 505.75 37% Of Billed Charges 2000 INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC inpatient 7600 3800 BCBS Louisiana PPO 3800 percent of total billed charges 3800 6460 50% of Eligible Charges INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC outpatient 7600 6080 BCBS Louisiana PPO 6080 percent of total billed charges 2812 6460 80% of billed charge INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC outpatient 7600 6080 Cigna Commercial PPO 4408 percent of total billed charges 2812 6460 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC inpatient 7600 3800 IMA of Louisiana Commercial PPO 6460 percent of total billed charges 3800 6460 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC outpatient 7600 6080 IMA of Louisiana Commercial PPO 6460 percent of total billed charges 2812 6460 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT LARGE - SHS PRODUC C1713 HCPCS 278 RC outpatient 7600 6080 Aetna Commercial PPO 2812 percent of total billed charges 2812 6460 37% Of Billed Charges 2000 SURGI-FLO 8ML C1713 HCPCS 272 RC inpatient 1187.1 593.55 BCBS Louisiana PPO 593.55 percent of total billed charges 593.55 1009.04 50% of Eligible Charges SURGI-FLO 8ML C1713 HCPCS 272 RC outpatient 1187.1 949.68 BCBS Louisiana PPO 949.68 percent of total billed charges 652.91 1009.04 80% of billed charge SURGI-FLO 8ML C1713 HCPCS 272 RC outpatient 1187.1 949.68 Cigna Commercial PPO 652.91 percent of total billed charges 652.91 1009.04 55% of Billed Charges SURGI-FLO 8ML C1713 HCPCS 272 RC inpatient 1187.1 593.55 IMA of Louisiana Commercial PPO 1009.04 percent of total billed charges 593.55 1009.04 Inpatient Reimbursement at 85% of Billed Charges SURGI-FLO 8ML C1713 HCPCS 272 RC outpatient 1187.1 949.68 IMA of Louisiana Commercial PPO 1009.04 percent of total billed charges 652.91 1009.04 Reimbursement at 85% of billed charges SURGI-FLO 8ML C1713 HCPCS 272 RC outpatient 1187.1 949.68 Aetna Commercial PPO 652.91 percent of total billed charges 652.91 1009.04 55 of billed Charges SUTURE ETHILON #1 CTX 830H 272 RC inpatient 6.44 3.22 BCBS Louisiana PPO 3.22 percent of total billed charges 3.22 5.47 50% of Eligible Charges SUTURE ETHILON #1 CTX 830H 272 RC outpatient 6.44 5.15 BCBS Louisiana PPO 5.15 percent of total billed charges 3.54 5.47 80% of billed charge SUTURE ETHILON #1 CTX 830H 272 RC outpatient 6.44 5.15 Cigna Commercial PPO 3.54 percent of total billed charges 3.54 5.47 55% of Billed Charges SUTURE ETHILON #1 CTX 830H 272 RC inpatient 6.44 3.22 IMA of Louisiana Commercial PPO 5.47 percent of total billed charges 3.22 5.47 Inpatient Reimbursement at 85% of Billed Charges SUTURE ETHILON #1 CTX 830H 272 RC outpatient 6.44 5.15 IMA of Louisiana Commercial PPO 5.47 percent of total billed charges 3.54 5.47 Reimbursement at 85% of billed charges SUTURE ETHILON #1 CTX 830H 272 RC outpatient 6.44 5.15 Aetna Commercial PPO 3.54 percent of total billed charges 3.54 5.47 55 of billed Charges SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC inpatient 9.32 4.66 BCBS Louisiana PPO 4.66 percent of total billed charges 4.66 7.92 50% of Eligible Charges SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC outpatient 9.32 7.46 BCBS Louisiana PPO 7.46 percent of total billed charges 5.13 7.92 80% of billed charge SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC outpatient 9.32 7.46 Cigna Commercial PPO 5.13 percent of total billed charges 5.13 7.92 55% of Billed Charges SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC inpatient 9.32 4.66 IMA of Louisiana Commercial PPO 7.92 percent of total billed charges 4.66 7.92 Inpatient Reimbursement at 85% of Billed Charges SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC outpatient 9.32 7.46 IMA of Louisiana Commercial PPO 7.92 percent of total billed charges 5.13 7.92 Reimbursement at 85% of billed charges SPINAL NEEDLE 25G X 3 1/2 - LETCHUMAN 272 RC outpatient 9.32 7.46 Aetna Commercial PPO 5.13 percent of total billed charges 5.13 7.92 55 of billed Charges SUTURE PROLENE 3-0 SH #8522H 272 RC inpatient 19.79 9.9 BCBS Louisiana PPO 9.9 percent of total billed charges 9.9 16.82 50% of Eligible Charges SUTURE PROLENE 3-0 SH #8522H 272 RC outpatient 19.79 15.83 BCBS Louisiana PPO 15.83 percent of total billed charges 10.88 16.82 80% of billed charge SUTURE PROLENE 3-0 SH #8522H 272 RC outpatient 19.79 15.83 Cigna Commercial PPO 10.88 percent of total billed charges 10.88 16.82 55% of Billed Charges SUTURE PROLENE 3-0 SH #8522H 272 RC inpatient 19.79 9.9 IMA of Louisiana Commercial PPO 16.82 percent of total billed charges 9.9 16.82 Inpatient Reimbursement at 85% of Billed Charges SUTURE PROLENE 3-0 SH #8522H 272 RC outpatient 19.79 15.83 IMA of Louisiana Commercial PPO 16.82 percent of total billed charges 10.88 16.82 Reimbursement at 85% of billed charges SUTURE PROLENE 3-0 SH #8522H 272 RC outpatient 19.79 15.83 Aetna Commercial PPO 10.88 percent of total billed charges 10.88 16.82 55 of billed Charges SYRINGE 10CC WITH NEEDLE 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges SYRINGE 10CC WITH NEEDLE 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge SYRINGE 10CC WITH NEEDLE 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges SYRINGE 10CC WITH NEEDLE 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 10CC WITH NEEDLE 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges SYRINGE 10CC WITH NEEDLE 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUTURE FIBERLOOP #2 #AR-7234 272 RC inpatient 780 390 BCBS Louisiana PPO 390 percent of total billed charges 390 663 50% of Eligible Charges SUTURE FIBERLOOP #2 #AR-7234 272 RC outpatient 780 624 BCBS Louisiana PPO 624 percent of total billed charges 429 663 80% of billed charge SUTURE FIBERLOOP #2 #AR-7234 272 RC outpatient 780 624 Cigna Commercial PPO 429 percent of total billed charges 429 663 55% of Billed Charges SUTURE FIBERLOOP #2 #AR-7234 272 RC inpatient 780 390 IMA of Louisiana Commercial PPO 663 percent of total billed charges 390 663 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERLOOP #2 #AR-7234 272 RC outpatient 780 624 IMA of Louisiana Commercial PPO 663 percent of total billed charges 429 663 Reimbursement at 85% of billed charges SUTURE FIBERLOOP #2 #AR-7234 272 RC outpatient 780 624 Aetna Commercial PPO 429 percent of total billed charges 429 663 55 of billed Charges RADIAL ARTERY CATHETER SET 272 RC inpatient 618 309 BCBS Louisiana PPO 309 percent of total billed charges 309 525.3 50% of Eligible Charges RADIAL ARTERY CATHETER SET 272 RC outpatient 618 494.4 BCBS Louisiana PPO 494.4 percent of total billed charges 339.9 525.3 80% of billed charge RADIAL ARTERY CATHETER SET 272 RC outpatient 618 494.4 Cigna Commercial PPO 339.9 percent of total billed charges 339.9 525.3 55% of Billed Charges RADIAL ARTERY CATHETER SET 272 RC inpatient 618 309 IMA of Louisiana Commercial PPO 525.3 percent of total billed charges 309 525.3 Inpatient Reimbursement at 85% of Billed Charges RADIAL ARTERY CATHETER SET 272 RC outpatient 618 494.4 IMA of Louisiana Commercial PPO 525.3 percent of total billed charges 339.9 525.3 Reimbursement at 85% of billed charges RADIAL ARTERY CATHETER SET 272 RC outpatient 618 494.4 Aetna Commercial PPO 339.9 percent of total billed charges 339.9 525.3 55 of billed Charges INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC inpatient 1262.5 631.25 BCBS Louisiana PPO 631.25 percent of total billed charges 631.25 1073.13 50% of Eligible Charges INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC outpatient 1262.5 1010 BCBS Louisiana PPO 1010 percent of total billed charges 467.13 1073.13 80% of billed charge INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC outpatient 1262.5 1010 Cigna Commercial PPO 732.25 percent of total billed charges 467.13 1073.13 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC inpatient 1262.5 631.25 IMA of Louisiana Commercial PPO 1073.13 percent of total billed charges 631.25 1073.13 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC outpatient 1262.5 1010 IMA of Louisiana Commercial PPO 1073.13 percent of total billed charges 467.13 1073.13 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT XX-SMALL - SHS PRO C1713 HCPCS 278 RC outpatient 1262.5 1010 Aetna Commercial PPO 467.13 percent of total billed charges 467.13 1073.13 37% Of Billed Charges 2000 AQUAMANTYS BIPOLAR SEALER 2.3 272 RC inpatient 583.46 291.73 BCBS Louisiana PPO 291.73 percent of total billed charges 291.73 495.94 50% of Eligible Charges AQUAMANTYS BIPOLAR SEALER 2.3 272 RC outpatient 583.46 466.77 BCBS Louisiana PPO 466.77 percent of total billed charges 320.9 495.94 80% of billed charge AQUAMANTYS BIPOLAR SEALER 2.3 272 RC outpatient 583.46 466.77 Cigna Commercial PPO 320.9 percent of total billed charges 320.9 495.94 55% of Billed Charges AQUAMANTYS BIPOLAR SEALER 2.3 272 RC inpatient 583.46 291.73 IMA of Louisiana Commercial PPO 495.94 percent of total billed charges 291.73 495.94 Inpatient Reimbursement at 85% of Billed Charges AQUAMANTYS BIPOLAR SEALER 2.3 272 RC outpatient 583.46 466.77 IMA of Louisiana Commercial PPO 495.94 percent of total billed charges 320.9 495.94 Reimbursement at 85% of billed charges AQUAMANTYS BIPOLAR SEALER 2.3 272 RC outpatient 583.46 466.77 Aetna Commercial PPO 320.9 percent of total billed charges 320.9 495.94 55 of billed Charges CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC inpatient 687.26 343.63 BCBS Louisiana PPO 343.63 percent of total billed charges 343.63 584.17 50% of Eligible Charges CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC outpatient 687.26 549.81 BCBS Louisiana PPO 549.81 percent of total billed charges 377.99 584.17 80% of billed charge CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC outpatient 687.26 549.81 Cigna Commercial PPO 377.99 percent of total billed charges 377.99 584.17 55% of Billed Charges CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC inpatient 687.26 343.63 IMA of Louisiana Commercial PPO 584.17 percent of total billed charges 343.63 584.17 Inpatient Reimbursement at 85% of Billed Charges CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC outpatient 687.26 549.81 IMA of Louisiana Commercial PPO 584.17 percent of total billed charges 377.99 584.17 Reimbursement at 85% of billed charges CAST SPLINT - FIBERGLASS (HAYNIE) 272 RC outpatient 687.26 549.81 Aetna Commercial PPO 377.99 percent of total billed charges 377.99 584.17 55 of billed Charges ARTERIAL SINGLE LINE KIT 272 RC inpatient 1120.25 560.13 BCBS Louisiana PPO 560.13 percent of total billed charges 560.13 952.21 50% of Eligible Charges ARTERIAL SINGLE LINE KIT 272 RC outpatient 1120.25 896.2 BCBS Louisiana PPO 896.2 percent of total billed charges 616.14 952.21 80% of billed charge ARTERIAL SINGLE LINE KIT 272 RC outpatient 1120.25 896.2 Cigna Commercial PPO 616.14 percent of total billed charges 616.14 952.21 55% of Billed Charges ARTERIAL SINGLE LINE KIT 272 RC inpatient 1120.25 560.13 IMA of Louisiana Commercial PPO 952.21 percent of total billed charges 560.13 952.21 Inpatient Reimbursement at 85% of Billed Charges ARTERIAL SINGLE LINE KIT 272 RC outpatient 1120.25 896.2 IMA of Louisiana Commercial PPO 952.21 percent of total billed charges 616.14 952.21 Reimbursement at 85% of billed charges ARTERIAL SINGLE LINE KIT 272 RC outpatient 1120.25 896.2 Aetna Commercial PPO 616.14 percent of total billed charges 616.14 952.21 55 of billed Charges GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC inpatient 297.5 148.75 BCBS Louisiana PPO 148.75 percent of total billed charges 148.75 252.88 50% of Eligible Charges GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC outpatient 297.5 238 BCBS Louisiana PPO 238 percent of total billed charges 110.08 252.88 80% of billed charge GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC outpatient 297.5 238 Cigna Commercial PPO 172.55 percent of total billed charges 110.08 252.88 58% of Billed Charges/$500 Threshold GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC inpatient 297.5 148.75 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 148.75 252.88 Inpatient Reimbursement at 85% of Billed Charges GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC outpatient 297.5 238 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 110.08 252.88 Reimbursement at 85% of billed charges GRAFT BTB PRE-CONT. BONE BLOCK 10MM C1713 HCPCS 278 RC outpatient 297.5 238 Aetna Commercial PPO 110.08 percent of total billed charges 110.08 252.88 37% Of Billed Charges 2000 DEPENDS BRIEF - SMALL 270 RC inpatient 1.08 0.54 BCBS Louisiana PPO 0.54 percent of total billed charges 0.54 0.92 50% of Eligible Charges DEPENDS BRIEF - SMALL 270 RC outpatient 1.08 0.86 BCBS Louisiana PPO 0.86 percent of total billed charges 0.59 0.92 80% of billed charge DEPENDS BRIEF - SMALL 270 RC outpatient 1.08 0.86 Cigna Commercial PPO 0.59 percent of total billed charges 0.59 0.92 55% of Billed Charges DEPENDS BRIEF - SMALL 270 RC inpatient 1.08 0.54 IMA of Louisiana Commercial PPO 0.92 percent of total billed charges 0.54 0.92 Inpatient Reimbursement at 85% of Billed Charges DEPENDS BRIEF - SMALL 270 RC outpatient 1.08 0.86 IMA of Louisiana Commercial PPO 0.92 percent of total billed charges 0.59 0.92 Reimbursement at 85% of billed charges DEPENDS BRIEF - SMALL 270 RC outpatient 1.08 0.86 Aetna Commercial PPO 0.59 percent of total billed charges 0.59 0.92 55 of billed Charges RF CANNULA 18 GA 10CM 10MM 272 RC inpatient 450 225 BCBS Louisiana PPO 225 percent of total billed charges 225 382.5 50% of Eligible Charges RF CANNULA 18 GA 10CM 10MM 272 RC outpatient 450 360 BCBS Louisiana PPO 360 percent of total billed charges 247.5 382.5 80% of billed charge RF CANNULA 18 GA 10CM 10MM 272 RC outpatient 450 360 Cigna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55% of Billed Charges RF CANNULA 18 GA 10CM 10MM 272 RC inpatient 450 225 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 225 382.5 Inpatient Reimbursement at 85% of Billed Charges RF CANNULA 18 GA 10CM 10MM 272 RC outpatient 450 360 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 247.5 382.5 Reimbursement at 85% of billed charges RF CANNULA 18 GA 10CM 10MM 272 RC outpatient 450 360 Aetna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55 of billed Charges CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC inpatient 96.81 48.41 BCBS Louisiana PPO 48.41 percent of total billed charges 48.41 82.29 50% of Eligible Charges CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC outpatient 96.81 77.45 BCBS Louisiana PPO 77.45 percent of total billed charges 53.25 82.29 80% of billed charge CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC outpatient 96.81 77.45 Cigna Commercial PPO 53.25 percent of total billed charges 53.25 82.29 55% of Billed Charges CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC inpatient 96.81 48.41 IMA of Louisiana Commercial PPO 82.29 percent of total billed charges 48.41 82.29 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC outpatient 96.81 77.45 IMA of Louisiana Commercial PPO 82.29 percent of total billed charges 53.25 82.29 Reimbursement at 85% of billed charges CATHETER FOLEY COUDE 12FR LATEX FREE 272 RC outpatient 96.81 77.45 Aetna Commercial PPO 53.25 percent of total billed charges 53.25 82.29 55 of billed Charges NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC inpatient 80.26 40.13 BCBS Louisiana PPO 40.13 percent of total billed charges 40.13 68.22 50% of Eligible Charges NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC outpatient 80.26 64.21 BCBS Louisiana PPO 64.21 percent of total billed charges 44.14 68.22 80% of billed charge NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC outpatient 80.26 64.21 Cigna Commercial PPO 44.14 percent of total billed charges 44.14 68.22 55% of Billed Charges NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC inpatient 80.26 40.13 IMA of Louisiana Commercial PPO 68.22 percent of total billed charges 40.13 68.22 Inpatient Reimbursement at 85% of Billed Charges NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC outpatient 80.26 64.21 IMA of Louisiana Commercial PPO 68.22 percent of total billed charges 44.14 68.22 Reimbursement at 85% of billed charges NEEDLE BONE MARROW JAMSHIDI 8GX6 272 RC outpatient 80.26 64.21 Aetna Commercial PPO 44.14 percent of total billed charges 44.14 68.22 55 of billed Charges RF CANNULA 20 GA 10CM 05MM 272 RC inpatient 450 225 BCBS Louisiana PPO 225 percent of total billed charges 225 382.5 50% of Eligible Charges RF CANNULA 20 GA 10CM 05MM 272 RC outpatient 450 360 BCBS Louisiana PPO 360 percent of total billed charges 247.5 382.5 80% of billed charge RF CANNULA 20 GA 10CM 05MM 272 RC outpatient 450 360 Cigna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55% of Billed Charges RF CANNULA 20 GA 10CM 05MM 272 RC inpatient 450 225 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 225 382.5 Inpatient Reimbursement at 85% of Billed Charges RF CANNULA 20 GA 10CM 05MM 272 RC outpatient 450 360 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 247.5 382.5 Reimbursement at 85% of billed charges RF CANNULA 20 GA 10CM 05MM 272 RC outpatient 450 360 Aetna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55 of billed Charges C-ARMOR DRAPE 272 RC inpatient 230.27 115.14 BCBS Louisiana PPO 115.14 percent of total billed charges 115.14 195.73 50% of Eligible Charges C-ARMOR DRAPE 272 RC outpatient 230.27 184.22 BCBS Louisiana PPO 184.22 percent of total billed charges 126.65 195.73 80% of billed charge C-ARMOR DRAPE 272 RC outpatient 230.27 184.22 Cigna Commercial PPO 126.65 percent of total billed charges 126.65 195.73 55% of Billed Charges C-ARMOR DRAPE 272 RC inpatient 230.27 115.14 IMA of Louisiana Commercial PPO 195.73 percent of total billed charges 115.14 195.73 Inpatient Reimbursement at 85% of Billed Charges C-ARMOR DRAPE 272 RC outpatient 230.27 184.22 IMA of Louisiana Commercial PPO 195.73 percent of total billed charges 126.65 195.73 Reimbursement at 85% of billed charges C-ARMOR DRAPE 272 RC outpatient 230.27 184.22 Aetna Commercial PPO 126.65 percent of total billed charges 126.65 195.73 55 of billed Charges CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC inpatient 72.96 36.48 BCBS Louisiana PPO 36.48 percent of total billed charges 36.48 62.02 50% of Eligible Charges CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC outpatient 72.96 58.37 BCBS Louisiana PPO 58.37 percent of total billed charges 40.13 62.02 80% of billed charge CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC outpatient 72.96 58.37 Cigna Commercial PPO 40.13 percent of total billed charges 40.13 62.02 55% of Billed Charges CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC inpatient 72.96 36.48 IMA of Louisiana Commercial PPO 62.02 percent of total billed charges 36.48 62.02 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC outpatient 72.96 58.37 IMA of Louisiana Commercial PPO 62.02 percent of total billed charges 40.13 62.02 Reimbursement at 85% of billed charges CATHETER COUDE LUB 12 FR 5CC- MCKESSON 272 RC outpatient 72.96 58.37 Aetna Commercial PPO 40.13 percent of total billed charges 40.13 62.02 55 of billed Charges GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC inpatient 464.49 232.25 BCBS Louisiana PPO 232.25 percent of total billed charges 232.25 394.82 50% of Eligible Charges GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC outpatient 464.49 371.59 BCBS Louisiana PPO 371.59 percent of total billed charges 255.47 394.82 80% of billed charge GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC outpatient 464.49 371.59 Cigna Commercial PPO 255.47 percent of total billed charges 255.47 394.82 55% of Billed Charges GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC inpatient 464.49 232.25 IMA of Louisiana Commercial PPO 394.82 percent of total billed charges 232.25 394.82 Inpatient Reimbursement at 85% of Billed Charges GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC outpatient 464.49 371.59 IMA of Louisiana Commercial PPO 394.82 percent of total billed charges 255.47 394.82 Reimbursement at 85% of billed charges GLIDEWIRE STRAIGHT STIFF - TERUMO 272 RC outpatient 464.49 371.59 Aetna Commercial PPO 255.47 percent of total billed charges 255.47 394.82 55 of billed Charges CANISTER W/ISOLYSER FOR VIA 272 RC inpatient 455.1 227.55 BCBS Louisiana PPO 227.55 percent of total billed charges 227.55 386.84 50% of Eligible Charges CANISTER W/ISOLYSER FOR VIA 272 RC outpatient 455.1 364.08 BCBS Louisiana PPO 364.08 percent of total billed charges 250.31 386.84 80% of billed charge CANISTER W/ISOLYSER FOR VIA 272 RC outpatient 455.1 364.08 Cigna Commercial PPO 250.31 percent of total billed charges 250.31 386.84 55% of Billed Charges CANISTER W/ISOLYSER FOR VIA 272 RC inpatient 455.1 227.55 IMA of Louisiana Commercial PPO 386.84 percent of total billed charges 227.55 386.84 Inpatient Reimbursement at 85% of Billed Charges CANISTER W/ISOLYSER FOR VIA 272 RC outpatient 455.1 364.08 IMA of Louisiana Commercial PPO 386.84 percent of total billed charges 250.31 386.84 Reimbursement at 85% of billed charges CANISTER W/ISOLYSER FOR VIA 272 RC outpatient 455.1 364.08 Aetna Commercial PPO 250.31 percent of total billed charges 250.31 386.84 55 of billed Charges VENOM NEEDLE 18GX150MM 272 RC inpatient 580 290 BCBS Louisiana PPO 290 percent of total billed charges 290 493 50% of Eligible Charges VENOM NEEDLE 18GX150MM 272 RC outpatient 580 464 BCBS Louisiana PPO 464 percent of total billed charges 319 493 80% of billed charge VENOM NEEDLE 18GX150MM 272 RC outpatient 580 464 Cigna Commercial PPO 319 percent of total billed charges 319 493 55% of Billed Charges VENOM NEEDLE 18GX150MM 272 RC inpatient 580 290 IMA of Louisiana Commercial PPO 493 percent of total billed charges 290 493 Inpatient Reimbursement at 85% of Billed Charges VENOM NEEDLE 18GX150MM 272 RC outpatient 580 464 IMA of Louisiana Commercial PPO 493 percent of total billed charges 319 493 Reimbursement at 85% of billed charges VENOM NEEDLE 18GX150MM 272 RC outpatient 580 464 Aetna Commercial PPO 319 percent of total billed charges 319 493 55 of billed Charges SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 BCBS Louisiana PPO 235.47 percent of total billed charges 235.47 400.29 50% of Eligible Charges SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 BCBS Louisiana PPO 376.74 percent of total billed charges 174.24 400.29 80% of billed charge SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Cigna Commercial PPO 273.14 percent of total billed charges 174.24 400.29 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 235.47 400.29 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 174.24 400.29 Reimbursement at 85% of billed charges SCREW 4.0MM CANN. 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Aetna Commercial PPO 174.24 percent of total billed charges 174.24 400.29 37% Of Billed Charges 2000 SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 BCBS Louisiana PPO 235.47 percent of total billed charges 235.47 400.29 50% of Eligible Charges SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 BCBS Louisiana PPO 376.74 percent of total billed charges 174.24 400.29 80% of billed charge SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Cigna Commercial PPO 273.14 percent of total billed charges 174.24 400.29 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 235.47 400.29 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 174.24 400.29 Reimbursement at 85% of billed charges SCREW 4.0MM CANN. 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Aetna Commercial PPO 174.24 percent of total billed charges 174.24 400.29 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 MASK ANES W/INFL PORT ADLT 270 RC inpatient 15.71 7.86 BCBS Louisiana PPO 7.86 percent of total billed charges 7.86 13.35 50% of Eligible Charges MASK ANES W/INFL PORT ADLT 270 RC outpatient 15.71 12.57 BCBS Louisiana PPO 12.57 percent of total billed charges 8.64 13.35 80% of billed charge MASK ANES W/INFL PORT ADLT 270 RC outpatient 15.71 12.57 Cigna Commercial PPO 8.64 percent of total billed charges 8.64 13.35 55% of Billed Charges MASK ANES W/INFL PORT ADLT 270 RC inpatient 15.71 7.86 IMA of Louisiana Commercial PPO 13.35 percent of total billed charges 7.86 13.35 Inpatient Reimbursement at 85% of Billed Charges MASK ANES W/INFL PORT ADLT 270 RC outpatient 15.71 12.57 IMA of Louisiana Commercial PPO 13.35 percent of total billed charges 8.64 13.35 Reimbursement at 85% of billed charges MASK ANES W/INFL PORT ADLT 270 RC outpatient 15.71 12.57 Aetna Commercial PPO 8.64 percent of total billed charges 8.64 13.35 55 of billed Charges CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC inpatient 473.76 236.88 BCBS Louisiana PPO 236.88 percent of total billed charges 236.88 402.7 50% of Eligible Charges CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC outpatient 473.76 379.01 BCBS Louisiana PPO 379.01 percent of total billed charges 260.57 402.7 80% of billed charge CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC outpatient 473.76 379.01 Cigna Commercial PPO 260.57 percent of total billed charges 260.57 402.7 55% of Billed Charges CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC inpatient 473.76 236.88 IMA of Louisiana Commercial PPO 402.7 percent of total billed charges 236.88 402.7 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC outpatient 473.76 379.01 IMA of Louisiana Commercial PPO 402.7 percent of total billed charges 260.57 402.7 Reimbursement at 85% of billed charges CATHETER COUDE LTX/TEF 18FR 5CC - GU DR 272 RC outpatient 473.76 379.01 Aetna Commercial PPO 260.57 percent of total billed charges 260.57 402.7 55 of billed Charges BUR 4.0MM ROUND 5820-10-240 272 RC inpatient 491.4 245.7 BCBS Louisiana PPO 245.7 percent of total billed charges 245.7 417.69 50% of Eligible Charges BUR 4.0MM ROUND 5820-10-240 272 RC outpatient 491.4 393.12 BCBS Louisiana PPO 393.12 percent of total billed charges 270.27 417.69 80% of billed charge BUR 4.0MM ROUND 5820-10-240 272 RC outpatient 491.4 393.12 Cigna Commercial PPO 270.27 percent of total billed charges 270.27 417.69 55% of Billed Charges BUR 4.0MM ROUND 5820-10-240 272 RC inpatient 491.4 245.7 IMA of Louisiana Commercial PPO 417.69 percent of total billed charges 245.7 417.69 Inpatient Reimbursement at 85% of Billed Charges BUR 4.0MM ROUND 5820-10-240 272 RC outpatient 491.4 393.12 IMA of Louisiana Commercial PPO 417.69 percent of total billed charges 270.27 417.69 Reimbursement at 85% of billed charges BUR 4.0MM ROUND 5820-10-240 272 RC outpatient 491.4 393.12 Aetna Commercial PPO 270.27 percent of total billed charges 270.27 417.69 55 of billed Charges SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC inpatient 47.04 23.52 BCBS Louisiana PPO 23.52 percent of total billed charges 23.52 39.98 50% of Eligible Charges SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC outpatient 47.04 37.63 BCBS Louisiana PPO 37.63 percent of total billed charges 25.87 39.98 80% of billed charge SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC outpatient 47.04 37.63 Cigna Commercial PPO 25.87 percent of total billed charges 25.87 39.98 55% of Billed Charges SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC inpatient 47.04 23.52 IMA of Louisiana Commercial PPO 39.98 percent of total billed charges 23.52 39.98 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC outpatient 47.04 37.63 IMA of Louisiana Commercial PPO 39.98 percent of total billed charges 25.87 39.98 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL CT-2 CR J726D 272 RC outpatient 47.04 37.63 Aetna Commercial PPO 25.87 percent of total billed charges 25.87 39.98 55 of billed Charges SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 212.122 C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 URINARY LEG BAG 270 RC inpatient 206.05 103.03 BCBS Louisiana PPO 103.03 percent of total billed charges 103.03 175.14 50% of Eligible Charges URINARY LEG BAG 270 RC outpatient 206.05 164.84 BCBS Louisiana PPO 164.84 percent of total billed charges 113.33 175.14 80% of billed charge URINARY LEG BAG 270 RC outpatient 206.05 164.84 Cigna Commercial PPO 113.33 percent of total billed charges 113.33 175.14 55% of Billed Charges URINARY LEG BAG 270 RC inpatient 206.05 103.03 IMA of Louisiana Commercial PPO 175.14 percent of total billed charges 103.03 175.14 Inpatient Reimbursement at 85% of Billed Charges URINARY LEG BAG 270 RC outpatient 206.05 164.84 IMA of Louisiana Commercial PPO 175.14 percent of total billed charges 113.33 175.14 Reimbursement at 85% of billed charges URINARY LEG BAG 270 RC outpatient 206.05 164.84 Aetna Commercial PPO 113.33 percent of total billed charges 113.33 175.14 55 of billed Charges DRAIN 7MM FLAT 272 RC inpatient 59.43 29.72 BCBS Louisiana PPO 29.72 percent of total billed charges 29.72 50.52 50% of Eligible Charges DRAIN 7MM FLAT 272 RC outpatient 59.43 47.54 BCBS Louisiana PPO 47.54 percent of total billed charges 32.69 50.52 80% of billed charge DRAIN 7MM FLAT 272 RC outpatient 59.43 47.54 Cigna Commercial PPO 32.69 percent of total billed charges 32.69 50.52 55% of Billed Charges DRAIN 7MM FLAT 272 RC inpatient 59.43 29.72 IMA of Louisiana Commercial PPO 50.52 percent of total billed charges 29.72 50.52 Inpatient Reimbursement at 85% of Billed Charges DRAIN 7MM FLAT 272 RC outpatient 59.43 47.54 IMA of Louisiana Commercial PPO 50.52 percent of total billed charges 32.69 50.52 Reimbursement at 85% of billed charges DRAIN 7MM FLAT 272 RC outpatient 59.43 47.54 Aetna Commercial PPO 32.69 percent of total billed charges 32.69 50.52 55 of billed Charges BUR 5.0 ROUND 5820-10-250 272 RC inpatient 367.5 183.75 BCBS Louisiana PPO 183.75 percent of total billed charges 183.75 312.38 50% of Eligible Charges BUR 5.0 ROUND 5820-10-250 272 RC outpatient 367.5 294 BCBS Louisiana PPO 294 percent of total billed charges 202.13 312.38 80% of billed charge BUR 5.0 ROUND 5820-10-250 272 RC outpatient 367.5 294 Cigna Commercial PPO 202.13 percent of total billed charges 202.13 312.38 55% of Billed Charges BUR 5.0 ROUND 5820-10-250 272 RC inpatient 367.5 183.75 IMA of Louisiana Commercial PPO 312.38 percent of total billed charges 183.75 312.38 Inpatient Reimbursement at 85% of Billed Charges BUR 5.0 ROUND 5820-10-250 272 RC outpatient 367.5 294 IMA of Louisiana Commercial PPO 312.38 percent of total billed charges 202.13 312.38 Reimbursement at 85% of billed charges BUR 5.0 ROUND 5820-10-250 272 RC outpatient 367.5 294 Aetna Commercial PPO 202.13 percent of total billed charges 202.13 312.38 55 of billed Charges PICC LINE PLACEMENT 36569 CPT 360 RC inpatient 2457.43 1228.72 BCBS Louisiana PPO 1228.72 percent of total billed charges 1228.72 2088.82 50% of Eligible Charges PICC LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 BCBS Louisiana PPO 1965.94 percent of total billed charges 1300 2088.82 80% of billed charges PICC LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 Cigna Commercial PPO 1351.59 percent of total billed charges 1300 2088.82 55% of Billed Charges PICC LINE PLACEMENT 36569 CPT 360 RC inpatient 2457.43 1228.72 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1228.72 2088.82 Inpatient Reimbursement at 85% of Billed Charges PICC LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1300 2088.82 Reimbursement at 85% of billed charges PICC LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 Aetna Commercial PPO 1300 fee schedule 1300 2088.82 Case Rate PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" inpatient 70.28 35.14 BCBS Louisiana PPO 35.14 percent of total billed charges 35.14 59.74 50% of Eligible Charges PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" outpatient 70.28 56.22 BCBS Louisiana PPO 56.22 percent of total billed charges 56.22 85 80% of billed charge PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" outpatient 70.28 56.22 Cigna Commercial PPO 85 other 56.22 85 63% of Billed Charges PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" inpatient 70.28 35.14 IMA of Louisiana Commercial PPO 59.74 percent of total billed charges 35.14 59.74 Inpatient Reimbursement at 85% of Billed Charges PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" outpatient 70.28 56.22 IMA of Louisiana Commercial PPO 59.74 percent of total billed charges 56.22 85 Reimbursement at 85% of billed charges PT MANUAL THERAPY TECHNIQUE 97140 CPT 421 RC "GP,59" outpatient 70.28 56.22 Aetna Commercial PPO 57.06 fee schedule 56.22 85 200% Of Aetna Market Fee Schedule PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" inpatient 52.38 26.19 BCBS Louisiana PPO 26.19 percent of total billed charges 26.19 44.52 50% of Eligible Charges PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" outpatient 52.38 41.9 BCBS Louisiana PPO 41.9 percent of total billed charges 41.9 85 80% of billed charge PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" outpatient 52.38 41.9 Cigna Commercial PPO 85 other 41.9 85 63% of Billed Charges PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" inpatient 52.38 26.19 IMA of Louisiana Commercial PPO 44.52 percent of total billed charges 26.19 44.52 Inpatient Reimbursement at 85% of Billed Charges PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" outpatient 52.38 41.9 IMA of Louisiana Commercial PPO 44.52 percent of total billed charges 41.9 85 Reimbursement at 85% of billed charges PT IONTOPHORESIS 97033 CPT 421 RC "GP,59" outpatient 52.38 41.9 Aetna Commercial PPO 49.34 fee schedule 41.9 85 200% Of Aetna Market Fee Schedule ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP inpatient 37.35 18.68 BCBS Louisiana PPO 18.68 percent of total billed charges 18.68 31.75 50% of Eligible Charges ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP outpatient 37.35 29.88 BCBS Louisiana PPO 29.88 percent of total billed charges 20.54 85 80% of billed charge ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP outpatient 37.35 29.88 Cigna Commercial PPO 85 other 20.54 85 63% of Billed Charges ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP inpatient 37.35 18.68 IMA of Louisiana Commercial PPO 31.75 percent of total billed charges 18.68 31.75 Inpatient Reimbursement at 85% of Billed Charges ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP outpatient 37.35 29.88 IMA of Louisiana Commercial PPO 31.75 percent of total billed charges 20.54 85 Reimbursement at 85% of billed charges ELECTRICAL STIMULATION UNATTENDED G0283 HCPCS 421 RC GP outpatient 37.35 29.88 Aetna Commercial PPO 20.54 percent of total billed charges 20.54 85 55 of billed Charges PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP inpatient 211.98 105.99 BCBS Louisiana PPO 105.99 percent of total billed charges 105.99 180.18 50% of Eligible Charges PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP outpatient 211.98 169.58 BCBS Louisiana PPO 169.58 percent of total billed charges 85 180.18 80% of billed charge PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP outpatient 211.98 169.58 Cigna Commercial PPO 85 other 85 180.18 63% of Billed Charges PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP inpatient 211.98 105.99 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 105.99 180.18 Inpatient Reimbursement at 85% of Billed Charges PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP outpatient 211.98 169.58 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 85 180.18 Reimbursement at 85% of billed charges PT EVAL MOD COMPLEX 30 MIN 97162 CPT 424 RC GP outpatient 211.98 169.58 Aetna Commercial PPO 158.42 fee schedule 85 180.18 200% Of Aetna Market Fee Schedule WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC inpatient 422.38 211.19 BCBS Louisiana PPO 211.19 percent of total billed charges 211.19 359.02 50% of Eligible Charges WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC outpatient 422.38 337.9 BCBS Louisiana PPO 337.9 percent of total billed charges 232.31 359.02 80% of billed charge WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC outpatient 422.38 337.9 Cigna Commercial PPO 232.31 percent of total billed charges 232.31 359.02 55% of Billed Charges WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC inpatient 422.38 211.19 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 211.19 359.02 Inpatient Reimbursement at 85% of Billed Charges WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC outpatient 422.38 337.9 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 232.31 359.02 Reimbursement at 85% of billed charges WOUND VAC PLACEMENT - LESS THAN 50CM 97605 CPT 360 RC outpatient 422.38 337.9 Aetna Commercial PPO 232.31 percent of total billed charges 232.31 359.02 55 of billed Charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC inpatient 1220.5 610.25 BCBS Louisiana PPO 610.25 percent of total billed charges 610.25 1037.43 50% of Eligible Charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC outpatient 1220.5 976.4 BCBS Louisiana PPO 976.4 percent of total billed charges 671.28 1300 80% of billed charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC outpatient 1220.5 976.4 Cigna Commercial PPO 671.28 percent of total billed charges 671.28 1300 55% of Billed Charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC inpatient 1220.5 610.25 IMA of Louisiana Commercial PPO 1037.43 percent of total billed charges 610.25 1037.43 Inpatient Reimbursement at 85% of Billed Charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC outpatient 1220.5 976.4 IMA of Louisiana Commercial PPO 1037.43 percent of total billed charges 671.28 1300 Reimbursement at 85% of billed charges WOUND VAC DRESSING CHANGE - DR OR PT 15852 CPT 360 RC outpatient 1220.5 976.4 Aetna Commercial PPO 1300 fee schedule 671.28 1300 Case Rate SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 BCBS Louisiana PPO 57.44 percent of total billed charges 57.44 97.64 50% of Eligible Charges SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 BCBS Louisiana PPO 91.9 percent of total billed charges 42.5 97.64 80% of billed charge SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Cigna Commercial PPO 66.62 percent of total billed charges 42.5 97.64 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 57.44 97.64 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 42.5 97.64 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Aetna Commercial PPO 42.5 percent of total billed charges 42.5 97.64 37% Of Billed Charges 2000 PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 453 226.5 BCBS Louisiana PPO 226.5 percent of total billed charges 226.5 385.05 50% of Eligible Charges PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 453 362.4 BCBS Louisiana PPO 362.4 percent of total billed charges 167.61 385.05 80% of billed charge PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 453 362.4 Cigna Commercial PPO 262.74 percent of total billed charges 167.61 385.05 58% of Billed Charges/$500 Threshold PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 453 226.5 IMA of Louisiana Commercial PPO 385.05 percent of total billed charges 226.5 385.05 Inpatient Reimbursement at 85% of Billed Charges PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 453 362.4 IMA of Louisiana Commercial PPO 385.05 percent of total billed charges 167.61 385.05 Reimbursement at 85% of billed charges PLATE STRAIGHT 2.4MM 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 453 362.4 Aetna Commercial PPO 167.61 percent of total billed charges 167.61 385.05 37% Of Billed Charges 2000 DRILL BIT 1.5MM - SYNTHES 272 RC inpatient 233.59 116.8 BCBS Louisiana PPO 116.8 percent of total billed charges 116.8 198.55 50% of Eligible Charges DRILL BIT 1.5MM - SYNTHES 272 RC outpatient 233.59 186.87 BCBS Louisiana PPO 186.87 percent of total billed charges 128.47 198.55 80% of billed charge DRILL BIT 1.5MM - SYNTHES 272 RC outpatient 233.59 186.87 Cigna Commercial PPO 128.47 percent of total billed charges 128.47 198.55 55% of Billed Charges DRILL BIT 1.5MM - SYNTHES 272 RC inpatient 233.59 116.8 IMA of Louisiana Commercial PPO 198.55 percent of total billed charges 116.8 198.55 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 1.5MM - SYNTHES 272 RC outpatient 233.59 186.87 IMA of Louisiana Commercial PPO 198.55 percent of total billed charges 128.47 198.55 Reimbursement at 85% of billed charges DRILL BIT 1.5MM - SYNTHES 272 RC outpatient 233.59 186.87 Aetna Commercial PPO 128.47 percent of total billed charges 128.47 198.55 55 of billed Charges NEEDLE KEITH STRAIGHT SZ 2 272 RC inpatient 523.15 261.58 BCBS Louisiana PPO 261.58 percent of total billed charges 261.58 444.68 50% of Eligible Charges NEEDLE KEITH STRAIGHT SZ 2 272 RC outpatient 523.15 418.52 BCBS Louisiana PPO 418.52 percent of total billed charges 287.73 444.68 80% of billed charge NEEDLE KEITH STRAIGHT SZ 2 272 RC outpatient 523.15 418.52 Cigna Commercial PPO 287.73 percent of total billed charges 287.73 444.68 55% of Billed Charges NEEDLE KEITH STRAIGHT SZ 2 272 RC inpatient 523.15 261.58 IMA of Louisiana Commercial PPO 444.68 percent of total billed charges 261.58 444.68 Inpatient Reimbursement at 85% of Billed Charges NEEDLE KEITH STRAIGHT SZ 2 272 RC outpatient 523.15 418.52 IMA of Louisiana Commercial PPO 444.68 percent of total billed charges 287.73 444.68 Reimbursement at 85% of billed charges NEEDLE KEITH STRAIGHT SZ 2 272 RC outpatient 523.15 418.52 Aetna Commercial PPO 287.73 percent of total billed charges 287.73 444.68 55 of billed Charges KNEE BRACE BLEDSO 24 270 RC inpatient 433.13 216.57 BCBS Louisiana PPO 216.57 percent of total billed charges 216.57 368.16 50% of Eligible Charges KNEE BRACE BLEDSO 24 270 RC outpatient 433.13 346.5 BCBS Louisiana PPO 346.5 percent of total billed charges 238.22 368.16 80% of billed charge KNEE BRACE BLEDSO 24 270 RC outpatient 433.13 346.5 Cigna Commercial PPO 238.22 percent of total billed charges 238.22 368.16 55% of Billed Charges KNEE BRACE BLEDSO 24 270 RC inpatient 433.13 216.57 IMA of Louisiana Commercial PPO 368.16 percent of total billed charges 216.57 368.16 Inpatient Reimbursement at 85% of Billed Charges KNEE BRACE BLEDSO 24 270 RC outpatient 433.13 346.5 IMA of Louisiana Commercial PPO 368.16 percent of total billed charges 238.22 368.16 Reimbursement at 85% of billed charges KNEE BRACE BLEDSO 24 270 RC outpatient 433.13 346.5 Aetna Commercial PPO 238.22 percent of total billed charges 238.22 368.16 55 of billed Charges CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC inpatient 157.5 78.75 BCBS Louisiana PPO 78.75 percent of total billed charges 78.75 133.88 50% of Eligible Charges CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC outpatient 157.5 126 BCBS Louisiana PPO 126 percent of total billed charges 58.28 133.88 80% of billed charge CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC outpatient 157.5 126 Cigna Commercial PPO 91.35 percent of total billed charges 58.28 133.88 58% of Billed Charges/$500 Threshold CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC inpatient 157.5 78.75 IMA of Louisiana Commercial PPO 133.88 percent of total billed charges 78.75 133.88 Inpatient Reimbursement at 85% of Billed Charges CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC outpatient 157.5 126 IMA of Louisiana Commercial PPO 133.88 percent of total billed charges 58.28 133.88 Reimbursement at 85% of billed charges CEMENT BIOMET BOND (PALACOS) - ZIMMER C1713 HCPCS 278 RC outpatient 157.5 126 Aetna Commercial PPO 58.28 percent of total billed charges 58.28 133.88 37% Of Billed Charges 2000 FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC inpatient 308.88 154.44 BCBS Louisiana PPO 154.44 percent of total billed charges 154.44 262.55 50% of Eligible Charges FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC outpatient 308.88 247.1 BCBS Louisiana PPO 247.1 percent of total billed charges 169.88 262.55 80% of billed charge FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC outpatient 308.88 247.1 Cigna Commercial PPO 169.88 percent of total billed charges 169.88 262.55 55% of Billed Charges FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC inpatient 308.88 154.44 IMA of Louisiana Commercial PPO 262.55 percent of total billed charges 154.44 262.55 Inpatient Reimbursement at 85% of Billed Charges FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC outpatient 308.88 247.1 IMA of Louisiana Commercial PPO 262.55 percent of total billed charges 169.88 262.55 Reimbursement at 85% of billed charges FILIFORM SPIRAL TIP STR 3 FR - GU CART 272 RC outpatient 308.88 247.1 Aetna Commercial PPO 169.88 percent of total billed charges 169.88 262.55 55 of billed Charges DIGIT WIDGET EXT. FIXATION DEVICE 270 RC inpatient 2062.5 1031.25 BCBS Louisiana PPO 1031.25 percent of total billed charges 1031.25 1753.13 50% of Eligible Charges DIGIT WIDGET EXT. FIXATION DEVICE 270 RC outpatient 2062.5 1650 BCBS Louisiana PPO 1650 percent of total billed charges 1134.38 1753.13 80% of billed charge DIGIT WIDGET EXT. FIXATION DEVICE 270 RC outpatient 2062.5 1650 Cigna Commercial PPO 1134.38 percent of total billed charges 1134.38 1753.13 55% of Billed Charges DIGIT WIDGET EXT. FIXATION DEVICE 270 RC inpatient 2062.5 1031.25 IMA of Louisiana Commercial PPO 1753.13 percent of total billed charges 1031.25 1753.13 Inpatient Reimbursement at 85% of Billed Charges DIGIT WIDGET EXT. FIXATION DEVICE 270 RC outpatient 2062.5 1650 IMA of Louisiana Commercial PPO 1753.13 percent of total billed charges 1134.38 1753.13 Reimbursement at 85% of billed charges DIGIT WIDGET EXT. FIXATION DEVICE 270 RC outpatient 2062.5 1650 Aetna Commercial PPO 1134.38 percent of total billed charges 1134.38 1753.13 55 of billed Charges PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 398.18 199.09 BCBS Louisiana PPO 199.09 percent of total billed charges 199.09 338.45 50% of Eligible Charges PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 398.18 318.54 BCBS Louisiana PPO 318.54 percent of total billed charges 147.33 338.45 80% of billed charge PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 398.18 318.54 Cigna Commercial PPO 230.94 percent of total billed charges 147.33 338.45 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 398.18 199.09 IMA of Louisiana Commercial PPO 338.45 percent of total billed charges 199.09 338.45 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 398.18 318.54 IMA of Louisiana Commercial PPO 338.45 percent of total billed charges 147.33 338.45 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR LCP 12 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 398.18 318.54 Aetna Commercial PPO 147.33 percent of total billed charges 147.33 338.45 37% Of Billed Charges 2000 GOWN MICROCOOL 2XL 272 RC inpatient 48.84 24.42 BCBS Louisiana PPO 24.42 percent of total billed charges 24.42 41.51 50% of Eligible Charges GOWN MICROCOOL 2XL 272 RC outpatient 48.84 39.07 BCBS Louisiana PPO 39.07 percent of total billed charges 26.86 41.51 80% of billed charge GOWN MICROCOOL 2XL 272 RC outpatient 48.84 39.07 Cigna Commercial PPO 26.86 percent of total billed charges 26.86 41.51 55% of Billed Charges GOWN MICROCOOL 2XL 272 RC inpatient 48.84 24.42 IMA of Louisiana Commercial PPO 41.51 percent of total billed charges 24.42 41.51 Inpatient Reimbursement at 85% of Billed Charges GOWN MICROCOOL 2XL 272 RC outpatient 48.84 39.07 IMA of Louisiana Commercial PPO 41.51 percent of total billed charges 26.86 41.51 Reimbursement at 85% of billed charges GOWN MICROCOOL 2XL 272 RC outpatient 48.84 39.07 Aetna Commercial PPO 26.86 percent of total billed charges 26.86 41.51 55 of billed Charges PICO WOUND KIT 14 DAY - LONG 272 RC inpatient 647.18 323.59 BCBS Louisiana PPO 323.59 percent of total billed charges 323.59 550.1 50% of Eligible Charges PICO WOUND KIT 14 DAY - LONG 272 RC outpatient 647.18 517.74 BCBS Louisiana PPO 517.74 percent of total billed charges 355.95 550.1 80% of billed charge PICO WOUND KIT 14 DAY - LONG 272 RC outpatient 647.18 517.74 Cigna Commercial PPO 355.95 percent of total billed charges 355.95 550.1 55% of Billed Charges PICO WOUND KIT 14 DAY - LONG 272 RC inpatient 647.18 323.59 IMA of Louisiana Commercial PPO 550.1 percent of total billed charges 323.59 550.1 Inpatient Reimbursement at 85% of Billed Charges PICO WOUND KIT 14 DAY - LONG 272 RC outpatient 647.18 517.74 IMA of Louisiana Commercial PPO 550.1 percent of total billed charges 355.95 550.1 Reimbursement at 85% of billed charges PICO WOUND KIT 14 DAY - LONG 272 RC outpatient 647.18 517.74 Aetna Commercial PPO 355.95 percent of total billed charges 355.95 550.1 55 of billed Charges DRESSING ALLEVY LIFE HEEL 272 RC inpatient 44 22 BCBS Louisiana PPO 22 percent of total billed charges 22 37.4 50% of Eligible Charges DRESSING ALLEVY LIFE HEEL 272 RC outpatient 44 35.2 BCBS Louisiana PPO 35.2 percent of total billed charges 24.2 37.4 80% of billed charge DRESSING ALLEVY LIFE HEEL 272 RC outpatient 44 35.2 Cigna Commercial PPO 24.2 percent of total billed charges 24.2 37.4 55% of Billed Charges DRESSING ALLEVY LIFE HEEL 272 RC inpatient 44 22 IMA of Louisiana Commercial PPO 37.4 percent of total billed charges 22 37.4 Inpatient Reimbursement at 85% of Billed Charges DRESSING ALLEVY LIFE HEEL 272 RC outpatient 44 35.2 IMA of Louisiana Commercial PPO 37.4 percent of total billed charges 24.2 37.4 Reimbursement at 85% of billed charges DRESSING ALLEVY LIFE HEEL 272 RC outpatient 44 35.2 Aetna Commercial PPO 24.2 percent of total billed charges 24.2 37.4 55 of billed Charges ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC inpatient 652.5 326.25 BCBS Louisiana PPO 326.25 percent of total billed charges 326.25 554.63 50% of Eligible Charges ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC outpatient 652.5 522 BCBS Louisiana PPO 522 percent of total billed charges 241.43 554.63 80% of billed charge ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC outpatient 652.5 522 Cigna Commercial PPO 378.45 percent of total billed charges 241.43 554.63 58% of Billed Charges/$500 Threshold ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC inpatient 652.5 326.25 IMA of Louisiana Commercial PPO 554.63 percent of total billed charges 326.25 554.63 Inpatient Reimbursement at 85% of Billed Charges ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC outpatient 652.5 522 IMA of Louisiana Commercial PPO 554.63 percent of total billed charges 241.43 554.63 Reimbursement at 85% of billed charges ULTRAFAST FIX 360 DELIVERY SYSTEM - S&N C1713 HCPCS 278 RC outpatient 652.5 522 Aetna Commercial PPO 241.43 percent of total billed charges 241.43 554.63 37% Of Billed Charges 2000 PRINEO DERMABOND 272 RC inpatient 474.38 237.19 BCBS Louisiana PPO 237.19 percent of total billed charges 237.19 403.22 50% of Eligible Charges PRINEO DERMABOND 272 RC outpatient 474.38 379.5 BCBS Louisiana PPO 379.5 percent of total billed charges 260.91 403.22 80% of billed charge PRINEO DERMABOND 272 RC outpatient 474.38 379.5 Cigna Commercial PPO 260.91 percent of total billed charges 260.91 403.22 55% of Billed Charges PRINEO DERMABOND 272 RC inpatient 474.38 237.19 IMA of Louisiana Commercial PPO 403.22 percent of total billed charges 237.19 403.22 Inpatient Reimbursement at 85% of Billed Charges PRINEO DERMABOND 272 RC outpatient 474.38 379.5 IMA of Louisiana Commercial PPO 403.22 percent of total billed charges 260.91 403.22 Reimbursement at 85% of billed charges PRINEO DERMABOND 272 RC outpatient 474.38 379.5 Aetna Commercial PPO 260.91 percent of total billed charges 260.91 403.22 55 of billed Charges CENTRAL LINE DRESSING CHANGE TRAY 272 RC inpatient 383.9 191.95 BCBS Louisiana PPO 191.95 percent of total billed charges 191.95 326.32 50% of Eligible Charges CENTRAL LINE DRESSING CHANGE TRAY 272 RC outpatient 383.9 307.12 BCBS Louisiana PPO 307.12 percent of total billed charges 211.15 326.32 80% of billed charge CENTRAL LINE DRESSING CHANGE TRAY 272 RC outpatient 383.9 307.12 Cigna Commercial PPO 211.15 percent of total billed charges 211.15 326.32 55% of Billed Charges CENTRAL LINE DRESSING CHANGE TRAY 272 RC inpatient 383.9 191.95 IMA of Louisiana Commercial PPO 326.32 percent of total billed charges 191.95 326.32 Inpatient Reimbursement at 85% of Billed Charges CENTRAL LINE DRESSING CHANGE TRAY 272 RC outpatient 383.9 307.12 IMA of Louisiana Commercial PPO 326.32 percent of total billed charges 211.15 326.32 Reimbursement at 85% of billed charges CENTRAL LINE DRESSING CHANGE TRAY 272 RC outpatient 383.9 307.12 Aetna Commercial PPO 211.15 percent of total billed charges 211.15 326.32 55 of billed Charges NASAL CANNULA WITH ETCO2 272 RC inpatient 231.11 115.56 BCBS Louisiana PPO 115.56 percent of total billed charges 115.56 196.44 50% of Eligible Charges NASAL CANNULA WITH ETCO2 272 RC outpatient 231.11 184.89 BCBS Louisiana PPO 184.89 percent of total billed charges 127.11 196.44 80% of billed charge NASAL CANNULA WITH ETCO2 272 RC outpatient 231.11 184.89 Cigna Commercial PPO 127.11 percent of total billed charges 127.11 196.44 55% of Billed Charges NASAL CANNULA WITH ETCO2 272 RC inpatient 231.11 115.56 IMA of Louisiana Commercial PPO 196.44 percent of total billed charges 115.56 196.44 Inpatient Reimbursement at 85% of Billed Charges NASAL CANNULA WITH ETCO2 272 RC outpatient 231.11 184.89 IMA of Louisiana Commercial PPO 196.44 percent of total billed charges 127.11 196.44 Reimbursement at 85% of billed charges NASAL CANNULA WITH ETCO2 272 RC outpatient 231.11 184.89 Aetna Commercial PPO 127.11 percent of total billed charges 127.11 196.44 55 of billed Charges INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC inpatient 4987.5 2493.75 BCBS Louisiana PPO 2493.75 percent of total billed charges 2493.75 4239.38 50% of Eligible Charges INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC outpatient 4987.5 3990 BCBS Louisiana PPO 3990 percent of total billed charges 1845.38 4239.38 80% of billed charge INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC outpatient 4987.5 3990 Cigna Commercial PPO 2892.75 percent of total billed charges 1845.38 4239.38 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC inpatient 4987.5 2493.75 IMA of Louisiana Commercial PPO 4239.38 percent of total billed charges 2493.75 4239.38 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC outpatient 4987.5 3990 IMA of Louisiana Commercial PPO 4239.38 percent of total billed charges 1845.38 4239.38 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT SMALL - SHS PRODUC C1713 HCPCS 278 RC outpatient 4987.5 3990 Aetna Commercial PPO 1845.38 percent of total billed charges 1845.38 4239.38 37% Of Billed Charges 2000 ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC inpatient 2251.25 1125.63 BCBS Louisiana PPO 1125.63 percent of total billed charges 1125.63 1913.56 50% of Eligible Charges ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC outpatient 2251.25 1801 BCBS Louisiana PPO 1801 percent of total billed charges 832.96 1913.56 80% of billed charge ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC outpatient 2251.25 1801 Cigna Commercial PPO 1305.73 percent of total billed charges 832.96 1913.56 58% of Billed Charges/$500 Threshold ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC inpatient 2251.25 1125.63 IMA of Louisiana Commercial PPO 1913.56 percent of total billed charges 1125.63 1913.56 Inpatient Reimbursement at 85% of Billed Charges ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC outpatient 2251.25 1801 IMA of Louisiana Commercial PPO 1913.56 percent of total billed charges 832.96 1913.56 Reimbursement at 85% of billed charges ACHILLES SPEEDBRIDGE 4.75X19.1 - ARTHREX C1713 HCPCS 278 RC outpatient 2251.25 1801 Aetna Commercial PPO 832.96 percent of total billed charges 832.96 1913.56 37% Of Billed Charges 2000 SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC inpatient 378 189 BCBS Louisiana PPO 189 percent of total billed charges 189 321.3 50% of Eligible Charges SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 378 302.4 BCBS Louisiana PPO 302.4 percent of total billed charges 139.86 321.3 80% of billed charge SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 378 302.4 Cigna Commercial PPO 219.24 percent of total billed charges 139.86 321.3 58% of Billed Charges/$500 Threshold SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC inpatient 378 189 IMA of Louisiana Commercial PPO 321.3 percent of total billed charges 189 321.3 Inpatient Reimbursement at 85% of Billed Charges SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 378 302.4 IMA of Louisiana Commercial PPO 321.3 percent of total billed charges 139.86 321.3 Reimbursement at 85% of billed charges SCREW 1.2MMX9MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 378 302.4 Aetna Commercial PPO 139.86 percent of total billed charges 139.86 321.3 37% Of Billed Charges 2000 SAW BLADE MAKO - NARROW #116171 272 RC inpatient 506.37 253.19 BCBS Louisiana PPO 253.19 percent of total billed charges 253.19 430.41 50% of Eligible Charges SAW BLADE MAKO - NARROW #116171 272 RC outpatient 506.37 405.1 BCBS Louisiana PPO 405.1 percent of total billed charges 278.5 430.41 80% of billed charge SAW BLADE MAKO - NARROW #116171 272 RC outpatient 506.37 405.1 Cigna Commercial PPO 278.5 percent of total billed charges 278.5 430.41 55% of Billed Charges SAW BLADE MAKO - NARROW #116171 272 RC inpatient 506.37 253.19 IMA of Louisiana Commercial PPO 430.41 percent of total billed charges 253.19 430.41 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE MAKO - NARROW #116171 272 RC outpatient 506.37 405.1 IMA of Louisiana Commercial PPO 430.41 percent of total billed charges 278.5 430.41 Reimbursement at 85% of billed charges SAW BLADE MAKO - NARROW #116171 272 RC outpatient 506.37 405.1 Aetna Commercial PPO 278.5 percent of total billed charges 278.5 430.41 55 of billed Charges ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC inpatient 2165.63 1082.82 BCBS Louisiana PPO 1082.82 percent of total billed charges 1082.82 1840.79 50% of Eligible Charges ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC outpatient 2165.63 1732.5 BCBS Louisiana PPO 1732.5 percent of total billed charges 801.28 1840.79 80% of billed charge ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC outpatient 2165.63 1732.5 Cigna Commercial PPO 1256.07 percent of total billed charges 801.28 1840.79 58% of Billed Charges/$500 Threshold ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC inpatient 2165.63 1082.82 IMA of Louisiana Commercial PPO 1840.79 percent of total billed charges 1082.82 1840.79 Inpatient Reimbursement at 85% of Billed Charges ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC outpatient 2165.63 1732.5 IMA of Louisiana Commercial PPO 1840.79 percent of total billed charges 801.28 1840.79 Reimbursement at 85% of billed charges ACHILLES TENDON GRAFT WITH CALCAN. C1713 HCPCS 278 RC outpatient 2165.63 1732.5 Aetna Commercial PPO 801.28 percent of total billed charges 801.28 1840.79 37% Of Billed Charges 2000 DEPENDS BRIEF - XLARGE 270 RC inpatient 2.4 1.2 BCBS Louisiana PPO 1.2 percent of total billed charges 1.2 2.04 50% of Eligible Charges DEPENDS BRIEF - XLARGE 270 RC outpatient 2.4 1.92 BCBS Louisiana PPO 1.92 percent of total billed charges 1.32 2.04 80% of billed charge DEPENDS BRIEF - XLARGE 270 RC outpatient 2.4 1.92 Cigna Commercial PPO 1.32 percent of total billed charges 1.32 2.04 55% of Billed Charges DEPENDS BRIEF - XLARGE 270 RC inpatient 2.4 1.2 IMA of Louisiana Commercial PPO 2.04 percent of total billed charges 1.2 2.04 Inpatient Reimbursement at 85% of Billed Charges DEPENDS BRIEF - XLARGE 270 RC outpatient 2.4 1.92 IMA of Louisiana Commercial PPO 2.04 percent of total billed charges 1.32 2.04 Reimbursement at 85% of billed charges DEPENDS BRIEF - XLARGE 270 RC outpatient 2.4 1.92 Aetna Commercial PPO 1.32 percent of total billed charges 1.32 2.04 55 of billed Charges CANNULA FLEX 8.0 X 72MM - S&N 272 RC inpatient 560 280 BCBS Louisiana PPO 280 percent of total billed charges 280 476 50% of Eligible Charges CANNULA FLEX 8.0 X 72MM - S&N 272 RC outpatient 560 448 BCBS Louisiana PPO 448 percent of total billed charges 308 476 80% of billed charge CANNULA FLEX 8.0 X 72MM - S&N 272 RC outpatient 560 448 Cigna Commercial PPO 308 percent of total billed charges 308 476 55% of Billed Charges CANNULA FLEX 8.0 X 72MM - S&N 272 RC inpatient 560 280 IMA of Louisiana Commercial PPO 476 percent of total billed charges 280 476 Inpatient Reimbursement at 85% of Billed Charges CANNULA FLEX 8.0 X 72MM - S&N 272 RC outpatient 560 448 IMA of Louisiana Commercial PPO 476 percent of total billed charges 308 476 Reimbursement at 85% of billed charges CANNULA FLEX 8.0 X 72MM - S&N 272 RC outpatient 560 448 Aetna Commercial PPO 308 percent of total billed charges 308 476 55 of billed Charges DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC inpatient 547.79 273.9 BCBS Louisiana PPO 273.9 percent of total billed charges 273.9 465.62 50% of Eligible Charges DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC outpatient 547.79 438.23 BCBS Louisiana PPO 438.23 percent of total billed charges 301.28 465.62 80% of billed charge DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC outpatient 547.79 438.23 Cigna Commercial PPO 301.28 percent of total billed charges 301.28 465.62 55% of Billed Charges DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC inpatient 547.79 273.9 IMA of Louisiana Commercial PPO 465.62 percent of total billed charges 273.9 465.62 Inpatient Reimbursement at 85% of Billed Charges DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC outpatient 547.79 438.23 IMA of Louisiana Commercial PPO 465.62 percent of total billed charges 301.28 465.62 Reimbursement at 85% of billed charges DUET EXTERNAL CSF DRAIN AND MONIT. KIT 272 RC outpatient 547.79 438.23 Aetna Commercial PPO 301.28 percent of total billed charges 301.28 465.62 55 of billed Charges BONE PIN 4MM X 170MM 272 RC inpatient 403.2 201.6 BCBS Louisiana PPO 201.6 percent of total billed charges 201.6 342.72 50% of Eligible Charges BONE PIN 4MM X 170MM 272 RC outpatient 403.2 322.56 BCBS Louisiana PPO 322.56 percent of total billed charges 221.76 342.72 80% of billed charge BONE PIN 4MM X 170MM 272 RC outpatient 403.2 322.56 Cigna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55% of Billed Charges BONE PIN 4MM X 170MM 272 RC inpatient 403.2 201.6 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 201.6 342.72 Inpatient Reimbursement at 85% of Billed Charges BONE PIN 4MM X 170MM 272 RC outpatient 403.2 322.56 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 221.76 342.72 Reimbursement at 85% of billed charges BONE PIN 4MM X 170MM 272 RC outpatient 403.2 322.56 Aetna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55 of billed Charges SAW BLADE SHORT OFFSET #277-096-250 272 RC inpatient 90.55 45.28 BCBS Louisiana PPO 45.28 percent of total billed charges 45.28 76.97 50% of Eligible Charges SAW BLADE SHORT OFFSET #277-096-250 272 RC outpatient 90.55 72.44 BCBS Louisiana PPO 72.44 percent of total billed charges 49.8 76.97 80% of billed charge SAW BLADE SHORT OFFSET #277-096-250 272 RC outpatient 90.55 72.44 Cigna Commercial PPO 49.8 percent of total billed charges 49.8 76.97 55% of Billed Charges SAW BLADE SHORT OFFSET #277-096-250 272 RC inpatient 90.55 45.28 IMA of Louisiana Commercial PPO 76.97 percent of total billed charges 45.28 76.97 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE SHORT OFFSET #277-096-250 272 RC outpatient 90.55 72.44 IMA of Louisiana Commercial PPO 76.97 percent of total billed charges 49.8 76.97 Reimbursement at 85% of billed charges SAW BLADE SHORT OFFSET #277-096-250 272 RC outpatient 90.55 72.44 Aetna Commercial PPO 49.8 percent of total billed charges 49.8 76.97 55 of billed Charges PICO WOUND KIT 14 DAY - SHORT 272 RC inpatient 647.18 323.59 BCBS Louisiana PPO 323.59 percent of total billed charges 323.59 550.1 50% of Eligible Charges PICO WOUND KIT 14 DAY - SHORT 272 RC outpatient 647.18 517.74 BCBS Louisiana PPO 517.74 percent of total billed charges 355.95 550.1 80% of billed charge PICO WOUND KIT 14 DAY - SHORT 272 RC outpatient 647.18 517.74 Cigna Commercial PPO 355.95 percent of total billed charges 355.95 550.1 55% of Billed Charges PICO WOUND KIT 14 DAY - SHORT 272 RC inpatient 647.18 323.59 IMA of Louisiana Commercial PPO 550.1 percent of total billed charges 323.59 550.1 Inpatient Reimbursement at 85% of Billed Charges PICO WOUND KIT 14 DAY - SHORT 272 RC outpatient 647.18 517.74 IMA of Louisiana Commercial PPO 550.1 percent of total billed charges 355.95 550.1 Reimbursement at 85% of billed charges PICO WOUND KIT 14 DAY - SHORT 272 RC outpatient 647.18 517.74 Aetna Commercial PPO 355.95 percent of total billed charges 355.95 550.1 55 of billed Charges ACL GRAFT KNIFE 10MM #232110 272 RC inpatient 1462.13 731.07 BCBS Louisiana PPO 731.07 percent of total billed charges 731.07 1242.81 50% of Eligible Charges ACL GRAFT KNIFE 10MM #232110 272 RC outpatient 1462.13 1169.7 BCBS Louisiana PPO 1169.7 percent of total billed charges 804.17 1242.81 80% of billed charge ACL GRAFT KNIFE 10MM #232110 272 RC outpatient 1462.13 1169.7 Cigna Commercial PPO 804.17 percent of total billed charges 804.17 1242.81 55% of Billed Charges ACL GRAFT KNIFE 10MM #232110 272 RC inpatient 1462.13 731.07 IMA of Louisiana Commercial PPO 1242.81 percent of total billed charges 731.07 1242.81 Inpatient Reimbursement at 85% of Billed Charges ACL GRAFT KNIFE 10MM #232110 272 RC outpatient 1462.13 1169.7 IMA of Louisiana Commercial PPO 1242.81 percent of total billed charges 804.17 1242.81 Reimbursement at 85% of billed charges ACL GRAFT KNIFE 10MM #232110 272 RC outpatient 1462.13 1169.7 Aetna Commercial PPO 804.17 percent of total billed charges 804.17 1242.81 55 of billed Charges BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC inpatient 750 375 BCBS Louisiana PPO 375 percent of total billed charges 375 637.5 50% of Eligible Charges BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC outpatient 750 600 BCBS Louisiana PPO 600 percent of total billed charges 277.5 637.5 80% of billed charge BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC outpatient 750 600 Cigna Commercial PPO 435 percent of total billed charges 277.5 637.5 58% of Billed Charges/$500 Threshold BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC inpatient 750 375 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 375 637.5 Inpatient Reimbursement at 85% of Billed Charges BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC outpatient 750 600 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 277.5 637.5 Reimbursement at 85% of billed charges BONE DBF 6CC - MEDTRONIC C1713 HCPCS 278 RC outpatient 750 600 Aetna Commercial PPO 277.5 percent of total billed charges 277.5 637.5 37% Of Billed Charges 2000 BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC inpatient 1267.5 633.75 BCBS Louisiana PPO 633.75 percent of total billed charges 633.75 1077.38 50% of Eligible Charges BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC outpatient 1267.5 1014 BCBS Louisiana PPO 1014 percent of total billed charges 468.98 1077.38 80% of billed charge BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC outpatient 1267.5 1014 Cigna Commercial PPO 735.15 percent of total billed charges 468.98 1077.38 58% of Billed Charges/$500 Threshold BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC inpatient 1267.5 633.75 IMA of Louisiana Commercial PPO 1077.38 percent of total billed charges 633.75 1077.38 Inpatient Reimbursement at 85% of Billed Charges BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC outpatient 1267.5 1014 IMA of Louisiana Commercial PPO 1077.38 percent of total billed charges 468.98 1077.38 Reimbursement at 85% of billed charges BIOCARTILAGE 1CC - ARTHREX C1713 HCPCS 278 RC outpatient 1267.5 1014 Aetna Commercial PPO 468.98 percent of total billed charges 468.98 1077.38 37% Of Billed Charges 2000 HIP ABDUCTION ORTHOSIS - STANDARD 270 RC inpatient 1255 627.5 BCBS Louisiana PPO 627.5 percent of total billed charges 627.5 1066.75 50% of Eligible Charges HIP ABDUCTION ORTHOSIS - STANDARD 270 RC outpatient 1255 1004 BCBS Louisiana PPO 1004 percent of total billed charges 690.25 1066.75 80% of billed charge HIP ABDUCTION ORTHOSIS - STANDARD 270 RC outpatient 1255 1004 Cigna Commercial PPO 690.25 percent of total billed charges 690.25 1066.75 55% of Billed Charges HIP ABDUCTION ORTHOSIS - STANDARD 270 RC inpatient 1255 627.5 IMA of Louisiana Commercial PPO 1066.75 percent of total billed charges 627.5 1066.75 Inpatient Reimbursement at 85% of Billed Charges HIP ABDUCTION ORTHOSIS - STANDARD 270 RC outpatient 1255 1004 IMA of Louisiana Commercial PPO 1066.75 percent of total billed charges 690.25 1066.75 Reimbursement at 85% of billed charges HIP ABDUCTION ORTHOSIS - STANDARD 270 RC outpatient 1255 1004 Aetna Commercial PPO 690.25 percent of total billed charges 690.25 1066.75 55 of billed Charges CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC inpatient 109.41 54.71 BCBS Louisiana PPO 54.71 percent of total billed charges 54.71 93 50% of Eligible Charges CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC outpatient 109.41 87.53 BCBS Louisiana PPO 87.53 percent of total billed charges 60.18 93 80% of billed charge CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC outpatient 109.41 87.53 Cigna Commercial PPO 60.18 percent of total billed charges 60.18 93 55% of Billed Charges CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC inpatient 109.41 54.71 IMA of Louisiana Commercial PPO 93 percent of total billed charges 54.71 93 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC outpatient 109.41 87.53 IMA of Louisiana Commercial PPO 93 percent of total billed charges 60.18 93 Reimbursement at 85% of billed charges CATHETER FOLEY COUDE 14FR LATEX FREE 272 RC outpatient 109.41 87.53 Aetna Commercial PPO 60.18 percent of total billed charges 60.18 93 55 of billed Charges ELECTRODE BAYONET #0029M 272 RC inpatient 97.3 48.65 BCBS Louisiana PPO 48.65 percent of total billed charges 48.65 82.71 50% of Eligible Charges ELECTRODE BAYONET #0029M 272 RC outpatient 97.3 77.84 BCBS Louisiana PPO 77.84 percent of total billed charges 53.52 82.71 80% of billed charge ELECTRODE BAYONET #0029M 272 RC outpatient 97.3 77.84 Cigna Commercial PPO 53.52 percent of total billed charges 53.52 82.71 55% of Billed Charges ELECTRODE BAYONET #0029M 272 RC inpatient 97.3 48.65 IMA of Louisiana Commercial PPO 82.71 percent of total billed charges 48.65 82.71 Inpatient Reimbursement at 85% of Billed Charges ELECTRODE BAYONET #0029M 272 RC outpatient 97.3 77.84 IMA of Louisiana Commercial PPO 82.71 percent of total billed charges 53.52 82.71 Reimbursement at 85% of billed charges ELECTRODE BAYONET #0029M 272 RC outpatient 97.3 77.84 Aetna Commercial PPO 53.52 percent of total billed charges 53.52 82.71 55 of billed Charges PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC inpatient 105 52.5 BCBS Louisiana PPO 52.5 percent of total billed charges 52.5 89.25 50% of Eligible Charges PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC outpatient 105 84 BCBS Louisiana PPO 84 percent of total billed charges 57.75 89.25 80% of billed charge PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC outpatient 105 84 Cigna Commercial PPO 57.75 percent of total billed charges 57.75 89.25 55% of Billed Charges PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC inpatient 105 52.5 IMA of Louisiana Commercial PPO 89.25 percent of total billed charges 52.5 89.25 Inpatient Reimbursement at 85% of Billed Charges PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC outpatient 105 84 IMA of Louisiana Commercial PPO 89.25 percent of total billed charges 57.75 89.25 Reimbursement at 85% of billed charges PASSING ELEVATOR SCS WADHWA - BOSTON 272 RC outpatient 105 84 Aetna Commercial PPO 57.75 percent of total billed charges 57.75 89.25 55 of billed Charges TMAX FACE MASK - S&N ENDO 272 RC inpatient 500 250 BCBS Louisiana PPO 250 percent of total billed charges 250 425 50% of Eligible Charges TMAX FACE MASK - S&N ENDO 272 RC outpatient 500 400 BCBS Louisiana PPO 400 percent of total billed charges 275 425 80% of billed charge TMAX FACE MASK - S&N ENDO 272 RC outpatient 500 400 Cigna Commercial PPO 275 percent of total billed charges 275 425 55% of Billed Charges TMAX FACE MASK - S&N ENDO 272 RC inpatient 500 250 IMA of Louisiana Commercial PPO 425 percent of total billed charges 250 425 Inpatient Reimbursement at 85% of Billed Charges TMAX FACE MASK - S&N ENDO 272 RC outpatient 500 400 IMA of Louisiana Commercial PPO 425 percent of total billed charges 275 425 Reimbursement at 85% of billed charges TMAX FACE MASK - S&N ENDO 272 RC outpatient 500 400 Aetna Commercial PPO 275 percent of total billed charges 275 425 55 of billed Charges VENOM NEEDLE 20GX100MM 272 RC inpatient 580.8 290.4 BCBS Louisiana PPO 290.4 percent of total billed charges 290.4 493.68 50% of Eligible Charges VENOM NEEDLE 20GX100MM 272 RC outpatient 580.8 464.64 BCBS Louisiana PPO 464.64 percent of total billed charges 319.44 493.68 80% of billed charge VENOM NEEDLE 20GX100MM 272 RC outpatient 580.8 464.64 Cigna Commercial PPO 319.44 percent of total billed charges 319.44 493.68 55% of Billed Charges VENOM NEEDLE 20GX100MM 272 RC inpatient 580.8 290.4 IMA of Louisiana Commercial PPO 493.68 percent of total billed charges 290.4 493.68 Inpatient Reimbursement at 85% of Billed Charges VENOM NEEDLE 20GX100MM 272 RC outpatient 580.8 464.64 IMA of Louisiana Commercial PPO 493.68 percent of total billed charges 319.44 493.68 Reimbursement at 85% of billed charges VENOM NEEDLE 20GX100MM 272 RC outpatient 580.8 464.64 Aetna Commercial PPO 319.44 percent of total billed charges 319.44 493.68 55 of billed Charges CAMERA HANDLE COVER 272 RC inpatient 605.03 302.52 BCBS Louisiana PPO 302.52 percent of total billed charges 302.52 514.28 50% of Eligible Charges CAMERA HANDLE COVER 272 RC outpatient 605.03 484.02 BCBS Louisiana PPO 484.02 percent of total billed charges 332.77 514.28 80% of billed charge CAMERA HANDLE COVER 272 RC outpatient 605.03 484.02 Cigna Commercial PPO 332.77 percent of total billed charges 332.77 514.28 55% of Billed Charges CAMERA HANDLE COVER 272 RC inpatient 605.03 302.52 IMA of Louisiana Commercial PPO 514.28 percent of total billed charges 302.52 514.28 Inpatient Reimbursement at 85% of Billed Charges CAMERA HANDLE COVER 272 RC outpatient 605.03 484.02 IMA of Louisiana Commercial PPO 514.28 percent of total billed charges 332.77 514.28 Reimbursement at 85% of billed charges CAMERA HANDLE COVER 272 RC outpatient 605.03 484.02 Aetna Commercial PPO 332.77 percent of total billed charges 332.77 514.28 55 of billed Charges ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC inpatient 956.25 478.13 BCBS Louisiana PPO 478.13 percent of total billed charges 478.13 812.81 50% of Eligible Charges ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC outpatient 956.25 765 BCBS Louisiana PPO 765 percent of total billed charges 525.94 812.81 80% of billed charge ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC outpatient 956.25 765 Cigna Commercial PPO 525.94 percent of total billed charges 525.94 812.81 55% of Billed Charges ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC inpatient 956.25 478.13 IMA of Louisiana Commercial PPO 812.81 percent of total billed charges 478.13 812.81 Inpatient Reimbursement at 85% of Billed Charges ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC outpatient 956.25 765 IMA of Louisiana Commercial PPO 812.81 percent of total billed charges 525.94 812.81 Reimbursement at 85% of billed charges ZIPLINE 16 CLOSURE DEVICE - ATCH HIP 272 RC outpatient 956.25 765 Aetna Commercial PPO 525.94 percent of total billed charges 525.94 812.81 55 of billed Charges BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC inpatient 425.43 212.72 BCBS Louisiana PPO 212.72 percent of total billed charges 212.72 361.62 50% of Eligible Charges BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC outpatient 425.43 340.34 BCBS Louisiana PPO 340.34 percent of total billed charges 233.99 361.62 80% of billed charge BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC outpatient 425.43 340.34 Cigna Commercial PPO 233.99 percent of total billed charges 233.99 361.62 55% of Billed Charges BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC inpatient 425.43 212.72 IMA of Louisiana Commercial PPO 361.62 percent of total billed charges 212.72 361.62 Inpatient Reimbursement at 85% of Billed Charges BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC outpatient 425.43 340.34 IMA of Louisiana Commercial PPO 361.62 percent of total billed charges 233.99 361.62 Reimbursement at 85% of billed charges BUR 14X3MM #14MH30T - UTTER/CAMPB 272 RC outpatient 425.43 340.34 Aetna Commercial PPO 233.99 percent of total billed charges 233.99 361.62 55 of billed Charges DRAPE VERTICAL ISOLATION W/INCISE 272 RC inpatient 108.5 54.25 BCBS Louisiana PPO 54.25 percent of total billed charges 54.25 92.23 50% of Eligible Charges DRAPE VERTICAL ISOLATION W/INCISE 272 RC outpatient 108.5 86.8 BCBS Louisiana PPO 86.8 percent of total billed charges 59.68 92.23 80% of billed charge DRAPE VERTICAL ISOLATION W/INCISE 272 RC outpatient 108.5 86.8 Cigna Commercial PPO 59.68 percent of total billed charges 59.68 92.23 55% of Billed Charges DRAPE VERTICAL ISOLATION W/INCISE 272 RC inpatient 108.5 54.25 IMA of Louisiana Commercial PPO 92.23 percent of total billed charges 54.25 92.23 Inpatient Reimbursement at 85% of Billed Charges DRAPE VERTICAL ISOLATION W/INCISE 272 RC outpatient 108.5 86.8 IMA of Louisiana Commercial PPO 92.23 percent of total billed charges 59.68 92.23 Reimbursement at 85% of billed charges DRAPE VERTICAL ISOLATION W/INCISE 272 RC outpatient 108.5 86.8 Aetna Commercial PPO 59.68 percent of total billed charges 59.68 92.23 55 of billed Charges OR SERVICES LEVEL 4 360 RC inpatient 3000 1500 BCBS Louisiana PPO 1500 percent of total billed charges 1500 2550 50% of Eligible Charges OR SERVICES LEVEL 4 360 RC outpatient 3000 2400 BCBS Louisiana PPO 2400 percent of total billed charges 1650 2550 80% of billed charge OR SERVICES LEVEL 4 360 RC outpatient 3000 2400 Cigna Commercial PPO 1650 percent of total billed charges 1650 2550 55% of Billed Charges OR SERVICES LEVEL 4 360 RC inpatient 3000 1500 IMA of Louisiana Commercial PPO 2550 percent of total billed charges 1500 2550 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 4 360 RC outpatient 3000 2400 IMA of Louisiana Commercial PPO 2550 percent of total billed charges 1650 2550 Reimbursement at 85% of billed charges OR SERVICES LEVEL 4 360 RC outpatient 3000 2400 Aetna Commercial PPO 1650 percent of total billed charges 1650 2550 55 of billed Charges OR SERVICES LEVEL 10 360 RC inpatient 30000 15000 BCBS Louisiana PPO 15000 percent of total billed charges 15000 25500 50% of Eligible Charges OR SERVICES LEVEL 10 360 RC outpatient 30000 24000 BCBS Louisiana PPO 24000 percent of total billed charges 16500 25500 80% of billed charge OR SERVICES LEVEL 10 360 RC outpatient 30000 24000 Cigna Commercial PPO 16500 percent of total billed charges 16500 25500 55% of Billed Charges OR SERVICES LEVEL 10 360 RC inpatient 30000 15000 IMA of Louisiana Commercial PPO 25500 percent of total billed charges 15000 25500 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 10 360 RC outpatient 30000 24000 IMA of Louisiana Commercial PPO 25500 percent of total billed charges 16500 25500 Reimbursement at 85% of billed charges OR SERVICES LEVEL 10 360 RC outpatient 30000 24000 Aetna Commercial PPO 16500 percent of total billed charges 16500 25500 55 of billed Charges OR SERVICES LEVEL 12 360 RC inpatient 45000 22500 BCBS Louisiana PPO 22500 percent of total billed charges 22500 38250 50% of Eligible Charges OR SERVICES LEVEL 12 360 RC outpatient 45000 36000 BCBS Louisiana PPO 36000 percent of total billed charges 24750 38250 80% of billed charge OR SERVICES LEVEL 12 360 RC outpatient 45000 36000 Cigna Commercial PPO 24750 percent of total billed charges 24750 38250 55% of Billed Charges OR SERVICES LEVEL 12 360 RC inpatient 45000 22500 IMA of Louisiana Commercial PPO 38250 percent of total billed charges 22500 38250 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 12 360 RC outpatient 45000 36000 IMA of Louisiana Commercial PPO 38250 percent of total billed charges 24750 38250 Reimbursement at 85% of billed charges OR SERVICES LEVEL 12 360 RC outpatient 45000 36000 Aetna Commercial PPO 24750 percent of total billed charges 24750 38250 55 of billed Charges PROC ROOM SERVICES 03 360 RC inpatient 993 496.5 BCBS Louisiana PPO 496.5 percent of total billed charges 496.5 844.05 50% of Eligible Charges PROC ROOM SERVICES 03 360 RC outpatient 993 794.4 BCBS Louisiana PPO 794.4 percent of total billed charges 546.15 844.05 80% of billed charge PROC ROOM SERVICES 03 360 RC outpatient 993 794.4 Cigna Commercial PPO 546.15 percent of total billed charges 546.15 844.05 55% of Billed Charges PROC ROOM SERVICES 03 360 RC inpatient 993 496.5 IMA of Louisiana Commercial PPO 844.05 percent of total billed charges 496.5 844.05 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 03 360 RC outpatient 993 794.4 IMA of Louisiana Commercial PPO 844.05 percent of total billed charges 546.15 844.05 Reimbursement at 85% of billed charges PROC ROOM SERVICES 03 360 RC outpatient 993 794.4 Aetna Commercial PPO 546.15 percent of total billed charges 546.15 844.05 55 of billed Charges PROC ROOM SERVICES 04 360 RC inpatient 1233 616.5 BCBS Louisiana PPO 616.5 percent of total billed charges 616.5 1048.05 50% of Eligible Charges PROC ROOM SERVICES 04 360 RC outpatient 1233 986.4 BCBS Louisiana PPO 986.4 percent of total billed charges 678.15 1048.05 80% of billed charge PROC ROOM SERVICES 04 360 RC outpatient 1233 986.4 Cigna Commercial PPO 678.15 percent of total billed charges 678.15 1048.05 55% of Billed Charges PROC ROOM SERVICES 04 360 RC inpatient 1233 616.5 IMA of Louisiana Commercial PPO 1048.05 percent of total billed charges 616.5 1048.05 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 04 360 RC outpatient 1233 986.4 IMA of Louisiana Commercial PPO 1048.05 percent of total billed charges 678.15 1048.05 Reimbursement at 85% of billed charges PROC ROOM SERVICES 04 360 RC outpatient 1233 986.4 Aetna Commercial PPO 678.15 percent of total billed charges 678.15 1048.05 55 of billed Charges PROC ROOM SERVICES 09 360 RC inpatient 1920 960 BCBS Louisiana PPO 960 percent of total billed charges 960 1632 50% of Eligible Charges PROC ROOM SERVICES 09 360 RC outpatient 1920 1536 BCBS Louisiana PPO 1536 percent of total billed charges 1056 1632 80% of billed charge PROC ROOM SERVICES 09 360 RC outpatient 1920 1536 Cigna Commercial PPO 1056 percent of total billed charges 1056 1632 55% of Billed Charges PROC ROOM SERVICES 09 360 RC inpatient 1920 960 IMA of Louisiana Commercial PPO 1632 percent of total billed charges 960 1632 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 09 360 RC outpatient 1920 1536 IMA of Louisiana Commercial PPO 1632 percent of total billed charges 1056 1632 Reimbursement at 85% of billed charges PROC ROOM SERVICES 09 360 RC outpatient 1920 1536 Aetna Commercial PPO 1056 percent of total billed charges 1056 1632 55 of billed Charges PROC ROOM SERVICES 10 360 RC inpatient 1922 961 BCBS Louisiana PPO 961 percent of total billed charges 961 1633.7 50% of Eligible Charges PROC ROOM SERVICES 10 360 RC outpatient 1922 1537.6 BCBS Louisiana PPO 1537.6 percent of total billed charges 1057.1 1633.7 80% of billed charge PROC ROOM SERVICES 10 360 RC outpatient 1922 1537.6 Cigna Commercial PPO 1057.1 percent of total billed charges 1057.1 1633.7 55% of Billed Charges PROC ROOM SERVICES 10 360 RC inpatient 1922 961 IMA of Louisiana Commercial PPO 1633.7 percent of total billed charges 961 1633.7 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 10 360 RC outpatient 1922 1537.6 IMA of Louisiana Commercial PPO 1633.7 percent of total billed charges 1057.1 1633.7 Reimbursement at 85% of billed charges PROC ROOM SERVICES 10 360 RC outpatient 1922 1537.6 Aetna Commercial PPO 1057.1 percent of total billed charges 1057.1 1633.7 55 of billed Charges PROC ROOM SERVICES 11 360 RC inpatient 2001 1000.5 BCBS Louisiana PPO 1000.5 percent of total billed charges 1000.5 1700.85 50% of Eligible Charges PROC ROOM SERVICES 11 360 RC outpatient 2001 1600.8 BCBS Louisiana PPO 1600.8 percent of total billed charges 1100.55 1700.85 80% of billed charge PROC ROOM SERVICES 11 360 RC outpatient 2001 1600.8 Cigna Commercial PPO 1100.55 percent of total billed charges 1100.55 1700.85 55% of Billed Charges PROC ROOM SERVICES 11 360 RC inpatient 2001 1000.5 IMA of Louisiana Commercial PPO 1700.85 percent of total billed charges 1000.5 1700.85 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 11 360 RC outpatient 2001 1600.8 IMA of Louisiana Commercial PPO 1700.85 percent of total billed charges 1100.55 1700.85 Reimbursement at 85% of billed charges PROC ROOM SERVICES 11 360 RC outpatient 2001 1600.8 Aetna Commercial PPO 1100.55 percent of total billed charges 1100.55 1700.85 55 of billed Charges PROC ROOM SERVICES 20 360 RC inpatient 3401 1700.5 BCBS Louisiana PPO 1700.5 percent of total billed charges 1700.5 2890.85 50% of Eligible Charges PROC ROOM SERVICES 20 360 RC outpatient 3401 2720.8 BCBS Louisiana PPO 2720.8 percent of total billed charges 1870.55 2890.85 80% of billed charge PROC ROOM SERVICES 20 360 RC outpatient 3401 2720.8 Cigna Commercial PPO 1870.55 percent of total billed charges 1870.55 2890.85 55% of Billed Charges PROC ROOM SERVICES 20 360 RC inpatient 3401 1700.5 IMA of Louisiana Commercial PPO 2890.85 percent of total billed charges 1700.5 2890.85 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 20 360 RC outpatient 3401 2720.8 IMA of Louisiana Commercial PPO 2890.85 percent of total billed charges 1870.55 2890.85 Reimbursement at 85% of billed charges PROC ROOM SERVICES 20 360 RC outpatient 3401 2720.8 Aetna Commercial PPO 1870.55 percent of total billed charges 1870.55 2890.85 55 of billed Charges REC RM 3.5 HR 710 RC inpatient 3675 1837.5 BCBS Louisiana PPO 1837.5 percent of total billed charges 1837.5 3123.75 50% of Eligible Charges REC RM 3.5 HR 710 RC outpatient 3675 2940 BCBS Louisiana PPO 2940 percent of total billed charges 2021.25 3123.75 80% of billed charge REC RM 3.5 HR 710 RC outpatient 3675 2940 Cigna Commercial PPO 2021.25 percent of total billed charges 2021.25 3123.75 55% of Billed Charges REC RM 3.5 HR 710 RC inpatient 3675 1837.5 IMA of Louisiana Commercial PPO 3123.75 percent of total billed charges 1837.5 3123.75 Inpatient Reimbursement at 85% of Billed Charges REC RM 3.5 HR 710 RC outpatient 3675 2940 IMA of Louisiana Commercial PPO 3123.75 percent of total billed charges 2021.25 3123.75 Reimbursement at 85% of billed charges REC RM 3.5 HR 710 RC outpatient 3675 2940 Aetna Commercial PPO 2021.25 percent of total billed charges 2021.25 3123.75 55 of billed Charges REC RM 4.0 HR 710 RC inpatient 4200 2100 BCBS Louisiana PPO 2100 percent of total billed charges 2100 3570 50% of Eligible Charges REC RM 4.0 HR 710 RC outpatient 4200 3360 BCBS Louisiana PPO 3360 percent of total billed charges 2310 3570 80% of billed charge REC RM 4.0 HR 710 RC outpatient 4200 3360 Cigna Commercial PPO 2310 percent of total billed charges 2310 3570 55% of Billed Charges REC RM 4.0 HR 710 RC inpatient 4200 2100 IMA of Louisiana Commercial PPO 3570 percent of total billed charges 2100 3570 Inpatient Reimbursement at 85% of Billed Charges REC RM 4.0 HR 710 RC outpatient 4200 3360 IMA of Louisiana Commercial PPO 3570 percent of total billed charges 2310 3570 Reimbursement at 85% of billed charges REC RM 4.0 HR 710 RC outpatient 4200 3360 Aetna Commercial PPO 2310 percent of total billed charges 2310 3570 55 of billed Charges REC ROOM 6.0 HR 710 RC inpatient 6300 3150 BCBS Louisiana PPO 3150 percent of total billed charges 3150 5355 50% of Eligible Charges REC ROOM 6.0 HR 710 RC outpatient 6300 5040 BCBS Louisiana PPO 5040 percent of total billed charges 3465 5355 80% of billed charge REC ROOM 6.0 HR 710 RC outpatient 6300 5040 Cigna Commercial PPO 3465 percent of total billed charges 3465 5355 55% of Billed Charges REC ROOM 6.0 HR 710 RC inpatient 6300 3150 IMA of Louisiana Commercial PPO 5355 percent of total billed charges 3150 5355 Inpatient Reimbursement at 85% of Billed Charges REC ROOM 6.0 HR 710 RC outpatient 6300 5040 IMA of Louisiana Commercial PPO 5355 percent of total billed charges 3465 5355 Reimbursement at 85% of billed charges REC ROOM 6.0 HR 710 RC outpatient 6300 5040 Aetna Commercial PPO 3465 percent of total billed charges 3465 5355 55 of billed Charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC inpatient 46.48 23.24 BCBS Louisiana PPO 23.24 percent of total billed charges 23.24 39.51 50% of Eligible Charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC outpatient 46.48 32.54 BCBS Louisiana PPO 32.54 percent of total billed charges 25.56 49.22 70% of billed charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC outpatient 46.48 32.54 Cigna Commercial PPO 25.56 percent of total billed charges 25.56 49.22 55% of Billed Charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC inpatient 46.48 23.24 IMA of Louisiana Commercial PPO 39.51 percent of total billed charges 23.24 39.51 Inpatient Reimbursement at 85% of Billed Charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC outpatient 46.48 32.54 IMA of Louisiana Commercial PPO 39.51 percent of total billed charges 25.56 49.22 Reimbursement at 85% of billed charges SERUM PREGNANCY (BHCG QUANTITATIVE) 84702 CPT 300 RC outpatient 46.48 32.54 Aetna Commercial PPO 49.22 fee schedule 25.56 49.22 200% Of Aetna Market Fee Schedule Hospital Technical Rate BUN 84520 CPT 300 RC inpatient 12.2 6.1 BCBS Louisiana PPO 6.1 percent of total billed charges 6.1 10.37 50% of Eligible Charges BUN 84520 CPT 300 RC outpatient 12.2 8.54 BCBS Louisiana PPO 8.54 percent of total billed charges 6.71 12.92 70% of billed charges BUN 84520 CPT 300 RC outpatient 12.2 8.54 Cigna Commercial PPO 6.71 percent of total billed charges 6.71 12.92 55% of Billed Charges BUN 84520 CPT 300 RC inpatient 12.2 6.1 IMA of Louisiana Commercial PPO 10.37 percent of total billed charges 6.1 10.37 Inpatient Reimbursement at 85% of Billed Charges BUN 84520 CPT 300 RC outpatient 12.2 8.54 IMA of Louisiana Commercial PPO 10.37 percent of total billed charges 6.71 12.92 Reimbursement at 85% of billed charges BUN 84520 CPT 300 RC outpatient 12.2 8.54 Aetna Commercial PPO 12.92 fee schedule 6.71 12.92 200% Of Aetna Market Fee Schedule Hospital Technical Rate CBC 85027 CPT 300 RC inpatient 19.95 9.98 BCBS Louisiana PPO 9.98 percent of total billed charges 9.98 16.96 50% of Eligible Charges CBC 85027 CPT 300 RC outpatient 19.95 13.97 BCBS Louisiana PPO 13.97 percent of total billed charges 10.97 21.14 70% of billed charges CBC 85027 CPT 300 RC outpatient 19.95 13.97 Cigna Commercial PPO 10.97 percent of total billed charges 10.97 21.14 55% of Billed Charges CBC 85027 CPT 300 RC inpatient 19.95 9.98 IMA of Louisiana Commercial PPO 16.96 percent of total billed charges 9.98 16.96 Inpatient Reimbursement at 85% of Billed Charges CBC 85027 CPT 300 RC outpatient 19.95 13.97 IMA of Louisiana Commercial PPO 16.96 percent of total billed charges 10.97 21.14 Reimbursement at 85% of billed charges CBC 85027 CPT 300 RC outpatient 19.95 13.97 Aetna Commercial PPO 21.14 fee schedule 10.97 21.14 200% Of Aetna Market Fee Schedule Hospital Technical Rate CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC inpatient 17 8.5 BCBS Louisiana PPO 8.5 percent of total billed charges 8.5 14.45 50% of Eligible Charges CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC outpatient 17 11.9 BCBS Louisiana PPO 11.9 percent of total billed charges 9.35 18 70% of billed charges CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC outpatient 17 11.9 Cigna Commercial PPO 9.35 percent of total billed charges 9.35 18 55% of Billed Charges CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC inpatient 17 8.5 IMA of Louisiana Commercial PPO 14.45 percent of total billed charges 8.5 14.45 Inpatient Reimbursement at 85% of Billed Charges CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC outpatient 17 11.9 IMA of Louisiana Commercial PPO 14.45 percent of total billed charges 9.35 18 Reimbursement at 85% of billed charges CELL COUNT-BODY FLUID/DIFF 89051 CPT 300 RC outpatient 17 11.9 Aetna Commercial PPO 18 fee schedule 9.35 18 200% Of Aetna Market Fee Schedule Hospital Technical Rate GLUCOSE 82947 CPT 300 RC inpatient 12.13 6.07 BCBS Louisiana PPO 6.07 percent of total billed charges 6.07 10.31 50% of Eligible Charges GLUCOSE 82947 CPT 300 RC outpatient 12.13 8.49 BCBS Louisiana PPO 8.49 percent of total billed charges 6.67 12.84 70% of billed charges GLUCOSE 82947 CPT 300 RC outpatient 12.13 8.49 Cigna Commercial PPO 6.67 percent of total billed charges 6.67 12.84 55% of Billed Charges GLUCOSE 82947 CPT 300 RC inpatient 12.13 6.07 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.07 10.31 Inpatient Reimbursement at 85% of Billed Charges GLUCOSE 82947 CPT 300 RC outpatient 12.13 8.49 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.67 12.84 Reimbursement at 85% of billed charges GLUCOSE 82947 CPT 300 RC outpatient 12.13 8.49 Aetna Commercial PPO 12.84 fee schedule 6.67 12.84 200% Of Aetna Market Fee Schedule Hospital Technical Rate HEMATOCRIT 85014 CPT 300 RC inpatient 7.33 3.67 BCBS Louisiana PPO 3.67 percent of total billed charges 3.67 6.23 50% of Eligible Charges HEMATOCRIT 85014 CPT 300 RC outpatient 7.33 5.13 BCBS Louisiana PPO 5.13 percent of total billed charges 4.03 7.76 70% of billed charges HEMATOCRIT 85014 CPT 300 RC outpatient 7.33 5.13 Cigna Commercial PPO 4.03 percent of total billed charges 4.03 7.76 55% of Billed Charges HEMATOCRIT 85014 CPT 300 RC inpatient 7.33 3.67 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 3.67 6.23 Inpatient Reimbursement at 85% of Billed Charges HEMATOCRIT 85014 CPT 300 RC outpatient 7.33 5.13 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 4.03 7.76 Reimbursement at 85% of billed charges HEMATOCRIT 85014 CPT 300 RC outpatient 7.33 5.13 Aetna Commercial PPO 7.76 fee schedule 4.03 7.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate PTT 85730 CPT 300 RC inpatient 18.55 9.28 BCBS Louisiana PPO 9.28 percent of total billed charges 9.28 15.77 50% of Eligible Charges PTT 85730 CPT 300 RC outpatient 18.55 12.99 BCBS Louisiana PPO 12.99 percent of total billed charges 10.2 19.64 70% of billed charges PTT 85730 CPT 300 RC outpatient 18.55 12.99 Cigna Commercial PPO 10.2 percent of total billed charges 10.2 19.64 55% of Billed Charges PTT 85730 CPT 300 RC inpatient 18.55 9.28 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 9.28 15.77 Inpatient Reimbursement at 85% of Billed Charges PTT 85730 CPT 300 RC outpatient 18.55 12.99 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 10.2 19.64 Reimbursement at 85% of billed charges PTT 85730 CPT 300 RC outpatient 18.55 12.99 Aetna Commercial PPO 19.64 fee schedule 10.2 19.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate RENAL FUNCTION PANEL 80069 CPT 300 RC inpatient 26.8 13.4 BCBS Louisiana PPO 13.4 percent of total billed charges 13.4 22.78 50% of Eligible Charges RENAL FUNCTION PANEL 80069 CPT 300 RC outpatient 26.8 18.76 BCBS Louisiana PPO 18.76 percent of total billed charges 14.74 28.4 70% of billed charges RENAL FUNCTION PANEL 80069 CPT 300 RC outpatient 26.8 18.76 Cigna Commercial PPO 14.74 percent of total billed charges 14.74 28.4 55% of Billed Charges RENAL FUNCTION PANEL 80069 CPT 300 RC inpatient 26.8 13.4 IMA of Louisiana Commercial PPO 22.78 percent of total billed charges 13.4 22.78 Inpatient Reimbursement at 85% of Billed Charges RENAL FUNCTION PANEL 80069 CPT 300 RC outpatient 26.8 18.76 IMA of Louisiana Commercial PPO 22.78 percent of total billed charges 14.74 28.4 Reimbursement at 85% of billed charges RENAL FUNCTION PANEL 80069 CPT 300 RC outpatient 26.8 18.76 Aetna Commercial PPO 28.4 fee schedule 14.74 28.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate CULTURE URINE ROUTINE 87086 CPT 300 RC inpatient 24.9 12.45 BCBS Louisiana PPO 12.45 percent of total billed charges 12.45 21.17 50% of Eligible Charges CULTURE URINE ROUTINE 87086 CPT 300 RC outpatient 24.9 17.43 BCBS Louisiana PPO 17.43 percent of total billed charges 13.7 26.4 70% of billed charges CULTURE URINE ROUTINE 87086 CPT 300 RC outpatient 24.9 17.43 Cigna Commercial PPO 13.7 percent of total billed charges 13.7 26.4 55% of Billed Charges CULTURE URINE ROUTINE 87086 CPT 300 RC inpatient 24.9 12.45 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 12.45 21.17 Inpatient Reimbursement at 85% of Billed Charges CULTURE URINE ROUTINE 87086 CPT 300 RC outpatient 24.9 17.43 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 13.7 26.4 Reimbursement at 85% of billed charges CULTURE URINE ROUTINE 87086 CPT 300 RC outpatient 24.9 17.43 Aetna Commercial PPO 26.4 fee schedule 13.7 26.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate PHOSPHORUS LEVEL 84100 CPT 300 RC inpatient 14.63 7.32 BCBS Louisiana PPO 7.32 percent of total billed charges 7.32 12.44 50% of Eligible Charges PHOSPHORUS LEVEL 84100 CPT 300 RC outpatient 14.63 10.24 BCBS Louisiana PPO 10.24 percent of total billed charges 8.05 15.5 70% of billed charges PHOSPHORUS LEVEL 84100 CPT 300 RC outpatient 14.63 10.24 Cigna Commercial PPO 8.05 percent of total billed charges 8.05 15.5 55% of Billed Charges PHOSPHORUS LEVEL 84100 CPT 300 RC inpatient 14.63 7.32 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 7.32 12.44 Inpatient Reimbursement at 85% of Billed Charges PHOSPHORUS LEVEL 84100 CPT 300 RC outpatient 14.63 10.24 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 8.05 15.5 Reimbursement at 85% of billed charges PHOSPHORUS LEVEL 84100 CPT 300 RC outpatient 14.63 10.24 Aetna Commercial PPO 15.5 fee schedule 8.05 15.5 200% Of Aetna Market Fee Schedule Hospital Technical Rate HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 BCBS Louisiana PPO 14.99 percent of total billed charges 14.99 25.48 50% of Eligible Charges HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 BCBS Louisiana PPO 20.99 percent of total billed charges 16.49 31.72 70% of billed charges HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Cigna Commercial PPO 16.49 percent of total billed charges 16.49 31.72 55% of Billed Charges HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 14.99 25.48 Inpatient Reimbursement at 85% of Billed Charges HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 16.49 31.72 Reimbursement at 85% of billed charges HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Aetna Commercial PPO 31.72 fee schedule 16.49 31.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate BLOOD CULTURE 87040 CPT 300 RC inpatient 31.85 15.93 BCBS Louisiana PPO 15.93 percent of total billed charges 15.93 27.07 50% of Eligible Charges BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 BCBS Louisiana PPO 22.3 percent of total billed charges 17.52 33.76 70% of billed charges BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 Cigna Commercial PPO 17.52 percent of total billed charges 17.52 33.76 55% of Billed Charges BLOOD CULTURE 87040 CPT 300 RC inpatient 31.85 15.93 IMA of Louisiana Commercial PPO 27.07 percent of total billed charges 15.93 27.07 Inpatient Reimbursement at 85% of Billed Charges BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 IMA of Louisiana Commercial PPO 27.07 percent of total billed charges 17.52 33.76 Reimbursement at 85% of billed charges BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 Aetna Commercial PPO 33.76 fee schedule 17.52 33.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate TROPONIN 1 84484 CPT 301 RC inpatient 31.18 15.59 BCBS Louisiana PPO 15.59 percent of total billed charges 15.59 26.5 50% of Eligible Charges TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 BCBS Louisiana PPO 21.83 percent of total billed charges 17.15 32.16 70% of billed charges TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 Cigna Commercial PPO 17.15 percent of total billed charges 17.15 32.16 55% of Billed Charges TROPONIN 1 84484 CPT 301 RC inpatient 31.18 15.59 IMA of Louisiana Commercial PPO 26.5 percent of total billed charges 15.59 26.5 Inpatient Reimbursement at 85% of Billed Charges TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 IMA of Louisiana Commercial PPO 26.5 percent of total billed charges 17.15 32.16 Reimbursement at 85% of billed charges TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 Aetna Commercial PPO 32.16 fee schedule 17.15 32.16 200% Of Aetna Market Fee Schedule Hospital Technical Rate VENIPUNCTURE 36415 CPT 300 RC inpatient 12 6 BCBS Louisiana PPO 6 percent of total billed charges 6 10.2 50% of Eligible Charges VENIPUNCTURE 36415 CPT 300 RC outpatient 12 9.6 BCBS Louisiana PPO 9.6 percent of total billed charges 6.6 10.2 80% of billed charge VENIPUNCTURE 36415 CPT 300 RC outpatient 12 9.6 Cigna Commercial PPO 6.6 percent of total billed charges 6.6 10.2 55% of Billed Charges VENIPUNCTURE 36415 CPT 300 RC inpatient 12 6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6 10.2 Inpatient Reimbursement at 85% of Billed Charges VENIPUNCTURE 36415 CPT 300 RC outpatient 12 9.6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6.6 10.2 Reimbursement at 85% of billed charges VENIPUNCTURE 36415 CPT 300 RC outpatient 12 9.6 Aetna Commercial PPO 8.7 fee schedule 6.6 10.2 200% Of Aetna Market Fee Schedule Hospital Technical Rate T3 FREE 84481 CPT 301 RC inpatient 52.3 26.15 BCBS Louisiana PPO 26.15 percent of total billed charges 26.15 44.46 50% of Eligible Charges T3 FREE 84481 CPT 301 RC outpatient 52.3 36.61 BCBS Louisiana PPO 36.61 percent of total billed charges 28.77 44.46 70% of billed charges T3 FREE 84481 CPT 301 RC outpatient 52.3 36.61 Cigna Commercial PPO 28.77 percent of total billed charges 28.77 44.46 55% of Billed Charges T3 FREE 84481 CPT 301 RC inpatient 52.3 26.15 IMA of Louisiana Commercial PPO 44.46 percent of total billed charges 26.15 44.46 Inpatient Reimbursement at 85% of Billed Charges T3 FREE 84481 CPT 301 RC outpatient 52.3 36.61 IMA of Louisiana Commercial PPO 44.46 percent of total billed charges 28.77 44.46 Reimbursement at 85% of billed charges T3 FREE 84481 CPT 301 RC outpatient 52.3 36.61 Aetna Commercial PPO 32.26 fee schedule 28.77 44.46 200% Of Aetna Market Fee Schedule Hospital Technical Rate CHOLESTEROL 82465 CPT 300 RC inpatient 13.43 6.72 BCBS Louisiana PPO 6.72 percent of total billed charges 6.72 11.42 50% of Eligible Charges CHOLESTEROL 82465 CPT 300 RC outpatient 13.43 9.4 BCBS Louisiana PPO 9.4 percent of total billed charges 7.39 14.2 70% of billed charges CHOLESTEROL 82465 CPT 300 RC outpatient 13.43 9.4 Cigna Commercial PPO 7.39 percent of total billed charges 7.39 14.2 55% of Billed Charges CHOLESTEROL 82465 CPT 300 RC inpatient 13.43 6.72 IMA of Louisiana Commercial PPO 11.42 percent of total billed charges 6.72 11.42 Inpatient Reimbursement at 85% of Billed Charges CHOLESTEROL 82465 CPT 300 RC outpatient 13.43 9.4 IMA of Louisiana Commercial PPO 11.42 percent of total billed charges 7.39 14.2 Reimbursement at 85% of billed charges CHOLESTEROL 82465 CPT 300 RC outpatient 13.43 9.4 Aetna Commercial PPO 14.2 fee schedule 7.39 14.2 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 BCBS Louisiana PPO 11.99 percent of total billed charges 11.99 20.38 50% of Eligible Charges prad_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 BCBS Louisiana PPO 16.79 percent of total billed charges 13.19 25.42 70% of billed charges prad_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Cigna Commercial PPO 13.19 percent of total billed charges 13.19 25.42 55% of Billed Charges prad_CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 11.99 20.38 Inpatient Reimbursement at 85% of Billed Charges prad_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 13.19 25.42 Reimbursement at 85% of billed charges prad_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Aetna Commercial PPO 25.42 fee schedule 13.19 25.42 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_URINALYSIS LABCORP 81001 CPT 300 RC inpatient 9.8 4.9 BCBS Louisiana PPO 4.9 percent of total billed charges 4.9 8.33 50% of Eligible Charges prad_URINALYSIS LABCORP 81001 CPT 300 RC outpatient 9.8 6.86 BCBS Louisiana PPO 6.86 percent of total billed charges 5.39 10.36 70% of billed charges prad_URINALYSIS LABCORP 81001 CPT 300 RC outpatient 9.8 6.86 Cigna Commercial PPO 5.39 percent of total billed charges 5.39 10.36 55% of Billed Charges prad_URINALYSIS LABCORP 81001 CPT 300 RC inpatient 9.8 4.9 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 4.9 8.33 Inpatient Reimbursement at 85% of Billed Charges prad_URINALYSIS LABCORP 81001 CPT 300 RC outpatient 9.8 6.86 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 5.39 10.36 Reimbursement at 85% of billed charges prad_URINALYSIS LABCORP 81001 CPT 300 RC outpatient 9.8 6.86 Aetna Commercial PPO 10.36 fee schedule 5.39 10.36 200% Of Aetna Market Fee Schedule Hospital Technical Rate SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC inpatient 111.75 55.88 BCBS Louisiana PPO 55.88 percent of total billed charges 55.88 94.99 50% of Eligible Charges SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC outpatient 111.75 78.23 BCBS Louisiana PPO 78.23 percent of total billed charges 61.46 94.99 70% of billed charges SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC outpatient 111.75 78.23 Cigna Commercial PPO 61.46 percent of total billed charges 61.46 94.99 55% of Billed Charges SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC inpatient 111.75 55.88 IMA of Louisiana Commercial PPO 94.99 percent of total billed charges 55.88 94.99 Inpatient Reimbursement at 85% of Billed Charges SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC outpatient 111.75 78.23 IMA of Louisiana Commercial PPO 94.99 percent of total billed charges 61.46 94.99 Reimbursement at 85% of billed charges SURGICAL PATHOLOGY CHARGE - DPGSURG 88304 CPT 310 RC outpatient 111.75 78.23 Aetna Commercial PPO 73.44 fee schedule 61.46 94.99 200% Of Aetna Market Fee Schedule Hospital Technical Rate MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC inpatient 108.33 54.17 BCBS Louisiana PPO 54.17 percent of total billed charges 54.17 92.08 50% of Eligible Charges MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 BCBS Louisiana PPO 75.83 percent of total billed charges 59.58 114.72 70% of billed charges MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 Cigna Commercial PPO 59.58 percent of total billed charges 59.58 114.72 55% of Billed Charges MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC inpatient 108.33 54.17 IMA of Louisiana Commercial PPO 92.08 percent of total billed charges 54.17 92.08 Inpatient Reimbursement at 85% of Billed Charges MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 IMA of Louisiana Commercial PPO 92.08 percent of total billed charges 59.58 114.72 Reimbursement at 85% of billed charges MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 Aetna Commercial PPO 114.72 fee schedule 59.58 114.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 BCBS Louisiana PPO 6.07 percent of total billed charges 6.07 10.31 50% of Eligible Charges inpt3_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 BCBS Louisiana PPO 8.49 percent of total billed charges 6.67 12.86 70% of billed charges inpt3_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Cigna Commercial PPO 6.67 percent of total billed charges 6.67 12.86 55% of Billed Charges inpt3_PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.07 10.31 Inpatient Reimbursement at 85% of Billed Charges inpt3_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.67 12.86 Reimbursement at 85% of billed charges inpt3_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Aetna Commercial PPO 12.86 fee schedule 6.67 12.86 200% Of Aetna Market Fee Schedule Hospital Technical Rate TESTOSTERONE 84403 CPT 300 RC inpatient 79.68 39.84 BCBS Louisiana PPO 39.84 percent of total billed charges 39.84 67.73 50% of Eligible Charges TESTOSTERONE 84403 CPT 300 RC outpatient 79.68 55.78 BCBS Louisiana PPO 55.78 percent of total billed charges 43.82 84.4 70% of billed charges TESTOSTERONE 84403 CPT 300 RC outpatient 79.68 55.78 Cigna Commercial PPO 43.82 percent of total billed charges 43.82 84.4 55% of Billed Charges TESTOSTERONE 84403 CPT 300 RC inpatient 79.68 39.84 IMA of Louisiana Commercial PPO 67.73 percent of total billed charges 39.84 67.73 Inpatient Reimbursement at 85% of Billed Charges TESTOSTERONE 84403 CPT 300 RC outpatient 79.68 55.78 IMA of Louisiana Commercial PPO 67.73 percent of total billed charges 43.82 84.4 Reimbursement at 85% of billed charges TESTOSTERONE 84403 CPT 300 RC outpatient 79.68 55.78 Aetna Commercial PPO 84.4 fee schedule 43.82 84.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC inpatient 78.63 39.32 BCBS Louisiana PPO 39.32 percent of total billed charges 39.32 66.84 50% of Eligible Charges "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC outpatient 78.63 55.04 BCBS Louisiana PPO 55.04 percent of total billed charges 43.25 83.26 70% of billed charges "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC outpatient 78.63 55.04 Cigna Commercial PPO 43.25 percent of total billed charges 43.25 83.26 55% of Billed Charges "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC inpatient 78.63 39.32 IMA of Louisiana Commercial PPO 66.84 percent of total billed charges 39.32 66.84 Inpatient Reimbursement at 85% of Billed Charges "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC outpatient 78.63 55.04 IMA of Louisiana Commercial PPO 66.84 percent of total billed charges 43.25 83.26 Reimbursement at 85% of billed charges "TESTOSTERONE FREE, ADULT MALE" 84402 CPT 300 RC outpatient 78.63 55.04 Aetna Commercial PPO 83.26 fee schedule 43.25 83.26 200% Of Aetna Market Fee Schedule Hospital Technical Rate HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC inpatient 265.35 132.68 BCBS Louisiana PPO 132.68 percent of total billed charges 132.68 225.55 50% of Eligible Charges HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC outpatient 265.35 185.75 BCBS Louisiana PPO 185.75 percent of total billed charges 145.94 225.55 70% of billed charges HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC outpatient 265.35 185.75 Cigna Commercial PPO 145.94 percent of total billed charges 145.94 225.55 55% of Billed Charges HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC inpatient 265.35 132.68 IMA of Louisiana Commercial PPO 225.55 percent of total billed charges 132.68 225.55 Inpatient Reimbursement at 85% of Billed Charges HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC outpatient 265.35 185.75 IMA of Louisiana Commercial PPO 225.55 percent of total billed charges 145.94 225.55 Reimbursement at 85% of billed charges HUMAN LEUKOCYTE ANTIGEN B27 86817 CPT 300 RC outpatient 265.35 185.75 Aetna Commercial PPO 210.48 fee schedule 145.94 225.55 200% Of Aetna Market Fee Schedule Hospital Technical Rate SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC inpatient 11.33 5.67 BCBS Louisiana PPO 5.67 percent of total billed charges 5.67 9.63 50% of Eligible Charges SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC outpatient 11.33 7.93 BCBS Louisiana PPO 7.93 percent of total billed charges 6.23 12 70% of billed charges SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC outpatient 11.33 7.93 Cigna Commercial PPO 6.23 percent of total billed charges 6.23 12 55% of Billed Charges SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC inpatient 11.33 5.67 IMA of Louisiana Commercial PPO 9.63 percent of total billed charges 5.67 9.63 Inpatient Reimbursement at 85% of Billed Charges SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC outpatient 11.33 7.93 IMA of Louisiana Commercial PPO 9.63 percent of total billed charges 6.23 12 Reimbursement at 85% of billed charges SERUM PROTEIN ELECTROPHORESIS 84155 CPT 300 RC outpatient 11.33 7.93 Aetna Commercial PPO 12 fee schedule 6.23 12 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_ D DIMER 85379 CPT 300 RC inpatient 31.4 15.7 BCBS Louisiana PPO 15.7 percent of total billed charges 15.7 26.69 50% of Eligible Charges inpt3_ D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 BCBS Louisiana PPO 21.98 percent of total billed charges 17.27 33.28 70% of billed charges inpt3_ D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 Cigna Commercial PPO 17.27 percent of total billed charges 17.27 33.28 55% of Billed Charges inpt3_ D DIMER 85379 CPT 300 RC inpatient 31.4 15.7 IMA of Louisiana Commercial PPO 26.69 percent of total billed charges 15.7 26.69 Inpatient Reimbursement at 85% of Billed Charges inpt3_ D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 IMA of Louisiana Commercial PPO 26.69 percent of total billed charges 17.27 33.28 Reimbursement at 85% of billed charges inpt3_ D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 Aetna Commercial PPO 33.28 fee schedule 17.27 33.28 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_ POTASSIUM 84132 CPT 300 RC inpatient 14.63 7.32 BCBS Louisiana PPO 7.32 percent of total billed charges 7.32 12.44 50% of Eligible Charges inpt3_ POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 BCBS Louisiana PPO 10.24 percent of total billed charges 8.05 15.02 70% of billed charges inpt3_ POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 Cigna Commercial PPO 8.05 percent of total billed charges 8.05 15.02 55% of Billed Charges inpt3_ POTASSIUM 84132 CPT 300 RC inpatient 14.63 7.32 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 7.32 12.44 Inpatient Reimbursement at 85% of Billed Charges inpt3_ POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 8.05 15.02 Reimbursement at 85% of billed charges inpt3_ POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 Aetna Commercial PPO 15.02 fee schedule 8.05 15.02 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_ URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 BCBS Louisiana PPO 6.98 percent of total billed charges 6.98 11.86 50% of Eligible Charges inpt3_ URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 BCBS Louisiana PPO 9.77 percent of total billed charges 7.67 14.78 70% of billed charges inpt3_ URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Cigna Commercial PPO 7.67 percent of total billed charges 7.67 14.78 55% of Billed Charges inpt3_ URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 6.98 11.86 Inpatient Reimbursement at 85% of Billed Charges inpt3_ URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 7.67 14.78 Reimbursement at 85% of billed charges inpt3_ URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Aetna Commercial PPO 14.78 fee schedule 7.67 14.78 200% Of Aetna Market Fee Schedule Hospital Technical Rate FOLATE 82746 CPT 301 RC inpatient 45.38 22.69 BCBS Louisiana PPO 22.69 percent of total billed charges 22.69 38.57 50% of Eligible Charges FOLATE 82746 CPT 301 RC outpatient 45.38 31.77 BCBS Louisiana PPO 31.77 percent of total billed charges 24.96 48.08 70% of billed charges FOLATE 82746 CPT 301 RC outpatient 45.38 31.77 Cigna Commercial PPO 24.96 percent of total billed charges 24.96 48.08 55% of Billed Charges FOLATE 82746 CPT 301 RC inpatient 45.38 22.69 IMA of Louisiana Commercial PPO 38.57 percent of total billed charges 22.69 38.57 Inpatient Reimbursement at 85% of Billed Charges FOLATE 82746 CPT 301 RC outpatient 45.38 31.77 IMA of Louisiana Commercial PPO 38.57 percent of total billed charges 24.96 48.08 Reimbursement at 85% of billed charges FOLATE 82746 CPT 301 RC outpatient 45.38 31.77 Aetna Commercial PPO 48.08 fee schedule 24.96 48.08 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_LIPID 80061 CPT 301 RC inpatient 41.33 20.67 BCBS Louisiana PPO 20.67 percent of total billed charges 20.67 35.13 50% of Eligible Charges inpt3_LIPID 80061 CPT 301 RC outpatient 41.33 28.93 BCBS Louisiana PPO 28.93 percent of total billed charges 22.73 39.1 70% of billed charges inpt3_LIPID 80061 CPT 301 RC outpatient 41.33 28.93 Cigna Commercial PPO 22.73 percent of total billed charges 22.73 39.1 55% of Billed Charges inpt3_LIPID 80061 CPT 301 RC inpatient 41.33 20.67 IMA of Louisiana Commercial PPO 35.13 percent of total billed charges 20.67 35.13 Inpatient Reimbursement at 85% of Billed Charges inpt3_LIPID 80061 CPT 301 RC outpatient 41.33 28.93 IMA of Louisiana Commercial PPO 35.13 percent of total billed charges 22.73 39.1 Reimbursement at 85% of billed charges inpt3_LIPID 80061 CPT 301 RC outpatient 41.33 28.93 Aetna Commercial PPO 39.1 fee schedule 22.73 39.1 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX CHEST SINGLE VI 71045 CPT 320 RC inpatient 230 115 BCBS Louisiana PPO 115 percent of total billed charges 115 195.5 50% of Eligible Charges XRAY DX CHEST SINGLE VI 71045 CPT 320 RC outpatient 230 161 BCBS Louisiana PPO 161 percent of total billed charges 126.5 700 70% of billed charges XRAY DX CHEST SINGLE VI 71045 CPT 320 RC outpatient 230 161 Cigna Commercial PPO 126.5 percent of total billed charges 126.5 700 55% of Billed Charges XRAY DX CHEST SINGLE VI 71045 CPT 320 RC inpatient 230 115 IMA of Louisiana Commercial PPO 195.5 percent of total billed charges 115 195.5 Inpatient Reimbursement at 85% of Billed Charges XRAY DX CHEST SINGLE VI 71045 CPT 320 RC outpatient 230 161 IMA of Louisiana Commercial PPO 195.5 percent of total billed charges 126.5 700 Reimbursement at 85% of billed charges XRAY DX CHEST SINGLE VI 71045 CPT 320 RC outpatient 230 161 Aetna Commercial PPO 700 case rate 126.5 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX RT HAND 2 VIEWS 73120 CPT 320 RC RT outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HUMERUS 73060 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT HUMERUS 73060 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT HUMERUS 73060 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT HUMERUS 73060 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HUMERUS 73060 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT HUMERUS 73060 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX SPINE CERVICAL 72040 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX SPINE CERVICAL 72040 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX SPINE CERVICAL 72040 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX SPINE CERVICAL 72040 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX SPINE CERVICAL 72040 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX SPINE CERVICAL 72040 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX SPINE LUMBOSACRAL 72100 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX LT FINGERS 73140 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT FINGERS 73140 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT FINGERS 73140 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT FINGERS 73140 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT FINGERS 73140 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT FINGERS 73140 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT HAND 3 VIEWS 73130 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT KNEE 2 VIEWS 73560 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 319.43 700 70% of billed charges C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Cigna Commercial PPO 319.43 percent of total billed charges 319.43 700 55% of Billed Charges C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 319.43 700 Reimbursement at 85% of billed charges C-ARM OR 5.01-10 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 319.43 700 700 Per Code Per DOS Paid In Addition C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 319.43 700 70% of billed charges C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Cigna Commercial PPO 319.43 percent of total billed charges 319.43 700 55% of Billed Charges C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 319.43 700 Reimbursement at 85% of billed charges C-ARM OR 10.01-15 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 319.43 700 700 Per Code Per DOS Paid In Addition XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC inpatient 90.45 45.23 BCBS Louisiana PPO 45.23 percent of total billed charges 45.23 76.88 50% of Eligible Charges XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC outpatient 90.45 63.32 BCBS Louisiana PPO 63.32 percent of total billed charges 49.75 700 70% of billed charges XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC outpatient 90.45 63.32 Cigna Commercial PPO 49.75 percent of total billed charges 49.75 700 55% of Billed Charges XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC inpatient 90.45 45.23 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 45.23 76.88 Inpatient Reimbursement at 85% of Billed Charges XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC outpatient 90.45 63.32 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 49.75 700 Reimbursement at 85% of billed charges XRAY DX AP/LAT CERVICAL SPINE - 2 VIEWS 72040 CPT 320 RC outpatient 90.45 63.32 Aetna Commercial PPO 700 case rate 49.75 700 700 Per Code Per DOS Paid In Addition MRI CERVICAL SPINE 72141 CPT 612 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI CERVICAL SPINE 72141 CPT 612 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI CERVICAL SPINE 72141 CPT 612 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI CERVICAL SPINE 72141 CPT 612 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI CERVICAL SPINE 72141 CPT 612 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI CERVICAL SPINE 72141 CPT 612 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 BCBS Louisiana PPO 2818.38 percent of total billed charges 700 3422.31 70% of billed charges C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Cigna Commercial PPO 2214.44 percent of total billed charges 700 3422.31 55% of Billed Charges C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 700 3422.31 Reimbursement at 85% of billed charges C-ARM DISCOGRAM 2ND LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Aetna Commercial PPO 700 case rate 700 3422.31 700 Per Code Per DOS Paid In Addition C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 BCBS Louisiana PPO 2818.38 percent of total billed charges 700 3422.31 70% of billed charges C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Cigna Commercial PPO 2214.44 percent of total billed charges 700 3422.31 55% of Billed Charges C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 700 3422.31 Reimbursement at 85% of billed charges C-ARM DISCOGRAM 3RD LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Aetna Commercial PPO 700 case rate 700 3422.31 700 Per Code Per DOS Paid In Addition C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC inpatient 2428.76 1214.38 BCBS Louisiana PPO 1214.38 percent of total billed charges 1214.38 2064.45 50% of Eligible Charges C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 2428.76 1943.01 BCBS Louisiana PPO 1943.01 percent of total billed charges 1300 2064.45 80% of billed charges C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 2428.76 1943.01 Cigna Commercial PPO 1335.82 percent of total billed charges 1300 2064.45 55% of Billed Charges C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC inpatient 2428.76 1214.38 IMA of Louisiana Commercial PPO 2064.45 percent of total billed charges 1214.38 2064.45 Inpatient Reimbursement at 85% of Billed Charges C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 2428.76 1943.01 IMA of Louisiana Commercial PPO 2064.45 percent of total billed charges 1300 2064.45 Reimbursement at 85% of billed charges C-ARM 1-5 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 2428.76 1943.01 Aetna Commercial PPO 1300 fee schedule 1300 2064.45 Case Rate "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges "C-ARM PAIN INJ. 1-5 MIN, SI , RHIZO" 77003 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges "C-ARM JNT INJ, TRIG PNT, PIRF, ASP, COC" 77002 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition CT PELVIS WITHOUT DYE 72192 CPT 350 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT PELVIS WITHOUT DYE 72192 CPT 350 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 200.31 700 70% of billed charges CT PELVIS WITHOUT DYE 72192 CPT 350 RC outpatient 286.15 200.31 Cigna Commercial PPO 700 other 200.31 700 $700 Per Visit CT PELVIS WITHOUT DYE 72192 CPT 350 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT PELVIS WITHOUT DYE 72192 CPT 350 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 200.31 700 Reimbursement at 85% of billed charges CT PELVIS WITHOUT DYE 72192 CPT 350 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 200.31 700 700 Per Code Per DOS Paid In Addition XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX WRIST RT 3 VIEW 73110 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC inpatient 139.9 69.95 BCBS Louisiana PPO 69.95 percent of total billed charges 69.95 118.92 50% of Eligible Charges ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC outpatient 139.9 111.92 BCBS Louisiana PPO 111.92 percent of total billed charges 76.95 118.92 80% of billed charges ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC outpatient 139.9 111.92 Cigna Commercial PPO 76.95 percent of total billed charges 76.95 118.92 55% of Billed Charges ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC inpatient 139.9 69.95 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 69.95 118.92 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC outpatient 139.9 111.92 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 76.95 118.92 Reimbursement at 85% of billed charges ULTRASOUND OF BLADDER - BLADDER SCAN 51798 CPT 360 RC outpatient 139.9 111.92 Aetna Commercial PPO 100 fee schedule 76.95 118.92 Case Rate X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC inpatient 67.6 33.8 BCBS Louisiana PPO 33.8 percent of total billed charges 33.8 57.46 50% of Eligible Charges X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC outpatient 67.6 47.32 BCBS Louisiana PPO 47.32 percent of total billed charges 37.18 700 70% of billed charges X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC outpatient 67.6 47.32 Cigna Commercial PPO 37.18 percent of total billed charges 37.18 700 55% of Billed Charges X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC inpatient 67.6 33.8 IMA of Louisiana Commercial PPO 57.46 percent of total billed charges 33.8 57.46 Inpatient Reimbursement at 85% of Billed Charges X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC outpatient 67.6 47.32 IMA of Louisiana Commercial PPO 57.46 percent of total billed charges 37.18 700 Reimbursement at 85% of billed charges X-RAY DX HIP 2 VIEW - RIGHT 73502 CPT 320 RC outpatient 67.6 47.32 Aetna Commercial PPO 700 case rate 37.18 700 700 Per Code Per DOS Paid In Addition LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC inpatient 5 ML 22.38 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 11.19 19.02 50% of Eligible Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 BCBS Louisiana PPO 17.9 percent of total billed charges 12.31 19.02 80% of billed charge LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 Cigna Commercial PPO 12.31 percent of total billed charges 12.31 19.02 55% of Billed Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC inpatient 5 ML 22.38 11.19 IMA of Louisiana Commercial PPO 19.02 percent of total billed charges 11.19 19.02 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 IMA of Louisiana Commercial PPO 19.02 percent of total billed charges 12.31 19.02 Reimbursement at 85% of billed charges CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC inpatient 10 ML 52.5 26.25 BCBS Louisiana PPO 26.25 percent of total billed charges 26.25 44.63 50% of Eligible Charges CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC outpatient 10 ML 52.5 42 BCBS Louisiana PPO 42 percent of total billed charges 28.88 44.63 80% of billed charge CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC outpatient 10 ML 52.5 42 Cigna Commercial PPO 28.88 percent of total billed charges 28.88 44.63 55% of Billed Charges CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC inpatient 10 ML 52.5 26.25 IMA of Louisiana Commercial PPO 44.63 percent of total billed charges 26.25 44.63 Inpatient Reimbursement at 85% of Billed Charges CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC outpatient 10 ML 52.5 42 IMA of Louisiana Commercial PPO 44.63 percent of total billed charges 28.88 44.63 Reimbursement at 85% of billed charges CALCIUM CHL 10% SYRINGE : 10ML 260 RC 0409163110 NDC outpatient 10 ML 52.5 42 Aetna Commercial PPO 28.88 percent of total billed charges 28.88 44.63 55 of billed Charges DEXAMETHASONE 10MG/ML 1ML PF J1100 HCPCS 250 RC 6332350616 NDC inpatient 10 ME 8.82 4.41 BCBS Louisiana PPO 4.41 percent of total billed charges 4.41 7.5 50% of Eligible Charges DEXAMETHASONE 10MG/ML 1ML PF J1100 HCPCS 250 RC 6332350616 NDC outpatient 10 ME 8.82 7.06 BCBS Louisiana PPO 7.06 percent of total billed charges 4.85 7.5 80% of billed charge DEXAMETHASONE 10MG/ML 1ML PF J1100 HCPCS 250 RC 6332350616 NDC outpatient 10 ME 8.82 7.06 Cigna Commercial PPO 4.85 percent of total billed charges 4.85 7.5 55% of Billed Charges DEXAMETHASONE 10MG/ML 1ML PF J1100 HCPCS 250 RC 6332350616 NDC inpatient 10 ME 8.82 4.41 IMA of Louisiana Commercial PPO 7.5 percent of total billed charges 4.41 7.5 Inpatient Reimbursement at 85% of Billed Charges DEXAMETHASONE 10MG/ML 1ML PF J1100 HCPCS 250 RC 6332350616 NDC outpatient 10 ME 8.82 7.06 IMA of Louisiana Commercial PPO 7.5 percent of total billed charges 4.85 7.5 Reimbursement at 85% of billed charges HYDROMORPHONE 2MG/ML 1ML J1170 HCPCS 250 RC 6332385325 NDC inpatient 2 ME 5.28 2.64 BCBS Louisiana PPO 2.64 percent of total billed charges 2.64 4.49 50% of Eligible Charges HYDROMORPHONE 2MG/ML 1ML J1170 HCPCS 250 RC 6332385325 NDC outpatient 2 ME 5.28 4.22 BCBS Louisiana PPO 4.22 percent of total billed charges 2.9 4.49 80% of billed charge HYDROMORPHONE 2MG/ML 1ML J1170 HCPCS 250 RC 6332385325 NDC outpatient 2 ME 5.28 4.22 Cigna Commercial PPO 2.9 percent of total billed charges 2.9 4.49 55% of Billed Charges HYDROMORPHONE 2MG/ML 1ML J1170 HCPCS 250 RC 6332385325 NDC inpatient 2 ME 5.28 2.64 IMA of Louisiana Commercial PPO 4.49 percent of total billed charges 2.64 4.49 Inpatient Reimbursement at 85% of Billed Charges HYDROMORPHONE 2MG/ML 1ML J1170 HCPCS 250 RC 6332385325 NDC outpatient 2 ME 5.28 4.22 IMA of Louisiana Commercial PPO 4.49 percent of total billed charges 2.9 4.49 Reimbursement at 85% of billed charges BISACODYL 10MG SUPP 250 RC 0574705050 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BISACODYL 10MG SUPP 250 RC 0574705050 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BISACODYL 10MG SUPP 250 RC 0574705050 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BISACODYL 10MG SUPP 250 RC 0574705050 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BISACODYL 10MG SUPP 250 RC 0574705050 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BISACODYL 10MG SUPP 250 RC 0574705050 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC inpatient 60 ME 1.17 0.59 BCBS Louisiana PPO 0.59 percent of total billed charges 0.59 0.99 50% of Eligible Charges PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC outpatient 60 ME 1.17 0.94 BCBS Louisiana PPO 0.94 percent of total billed charges 0.64 0.99 80% of billed charge PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC outpatient 60 ME 1.17 0.94 Cigna Commercial PPO 0.64 percent of total billed charges 0.64 0.99 55% of Billed Charges PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC inpatient 60 ME 1.17 0.59 IMA of Louisiana Commercial PPO 0.99 percent of total billed charges 0.59 0.99 Inpatient Reimbursement at 85% of Billed Charges PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC outpatient 60 ME 1.17 0.94 IMA of Louisiana Commercial PPO 0.99 percent of total billed charges 0.64 0.99 Reimbursement at 85% of billed charges PROPRANOLOL HCL ER 60MG CAPSULE 250 RC 0527411637 NDC outpatient 60 ME 1.17 0.94 Aetna Commercial PPO 0.64 percent of total billed charges 0.64 0.99 55 of billed Charges ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC inpatient 250 ML 43.6 21.8 BCBS Louisiana PPO 21.8 percent of total billed charges 21.8 37.06 50% of Eligible Charges ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC outpatient 250 ML 43.6 34.88 BCBS Louisiana PPO 34.88 percent of total billed charges 23.98 37.06 80% of billed charge ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC outpatient 250 ML 43.6 34.88 Cigna Commercial PPO 23.98 percent of total billed charges 23.98 37.06 55% of Billed Charges ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC inpatient 250 ML 43.6 21.8 IMA of Louisiana Commercial PPO 37.06 percent of total billed charges 21.8 37.06 Inpatient Reimbursement at 85% of Billed Charges ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC outpatient 250 ML 43.6 34.88 IMA of Louisiana Commercial PPO 37.06 percent of total billed charges 23.98 37.06 Reimbursement at 85% of billed charges ISOFLURANE INHALANT 250ML 250 RC 6679401725 NDC outpatient 250 ML 43.6 34.88 Aetna Commercial PPO 23.98 percent of total billed charges 23.98 37.06 55 of billed Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC inpatient 1 EA 253 126.5 BCBS Louisiana PPO 126.5 percent of total billed charges 126.5 215.05 50% of Eligible Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 BCBS Louisiana PPO 202.4 percent of total billed charges 139.15 215.05 80% of billed charge GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 Cigna Commercial PPO 139.15 percent of total billed charges 139.15 215.05 55% of Billed Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC inpatient 1 EA 253 126.5 IMA of Louisiana Commercial PPO 215.05 percent of total billed charges 126.5 215.05 Inpatient Reimbursement at 85% of Billed Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 IMA of Louisiana Commercial PPO 215.05 percent of total billed charges 139.15 215.05 Reimbursement at 85% of billed charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 Aetna Commercial PPO 139.15 percent of total billed charges 139.15 215.05 55 of billed Charges HEPARIN SODIUM 100U/ML 5ML SYRINGE J1642 HCPCS 250 RC 6425333335 NDC inpatient 5 ML 3.36 1.68 BCBS Louisiana PPO 1.68 percent of total billed charges 1.68 2.86 50% of Eligible Charges HEPARIN SODIUM 100U/ML 5ML SYRINGE J1642 HCPCS 250 RC 6425333335 NDC outpatient 5 ML 3.36 2.69 BCBS Louisiana PPO 2.69 percent of total billed charges 1.85 2.86 80% of billed charge HEPARIN SODIUM 100U/ML 5ML SYRINGE J1642 HCPCS 250 RC 6425333335 NDC outpatient 5 ML 3.36 2.69 Cigna Commercial PPO 1.85 percent of total billed charges 1.85 2.86 55% of Billed Charges HEPARIN SODIUM 100U/ML 5ML SYRINGE J1642 HCPCS 250 RC 6425333335 NDC inpatient 5 ML 3.36 1.68 IMA of Louisiana Commercial PPO 2.86 percent of total billed charges 1.68 2.86 Inpatient Reimbursement at 85% of Billed Charges HEPARIN SODIUM 100U/ML 5ML SYRINGE J1642 HCPCS 250 RC 6425333335 NDC outpatient 5 ML 3.36 2.69 IMA of Louisiana Commercial PPO 2.86 percent of total billed charges 1.85 2.86 Reimbursement at 85% of billed charges INSULIN HUMULIN R 100U/ML 10ML NON-FORM J1815 HCPCS 250 RC 0002821501 NDC inpatient 10 ML 256.95 128.48 BCBS Louisiana PPO 128.48 percent of total billed charges 128.48 218.41 50% of Eligible Charges INSULIN HUMULIN R 100U/ML 10ML NON-FORM J1815 HCPCS 250 RC 0002821501 NDC outpatient 10 ML 256.95 205.56 BCBS Louisiana PPO 205.56 percent of total billed charges 141.32 218.41 80% of billed charge INSULIN HUMULIN R 100U/ML 10ML NON-FORM J1815 HCPCS 250 RC 0002821501 NDC outpatient 10 ML 256.95 205.56 Cigna Commercial PPO 141.32 percent of total billed charges 141.32 218.41 55% of Billed Charges INSULIN HUMULIN R 100U/ML 10ML NON-FORM J1815 HCPCS 250 RC 0002821501 NDC inpatient 10 ML 256.95 128.48 IMA of Louisiana Commercial PPO 218.41 percent of total billed charges 128.48 218.41 Inpatient Reimbursement at 85% of Billed Charges INSULIN HUMULIN R 100U/ML 10ML NON-FORM J1815 HCPCS 250 RC 0002821501 NDC outpatient 10 ML 256.95 205.56 IMA of Louisiana Commercial PPO 218.41 percent of total billed charges 141.32 218.41 Reimbursement at 85% of billed charges LIDOCAINE 1% 5ML AMP J2001 HCPCS 250 RC 6332349236 NDC inpatient 5 ML 5.52 2.76 BCBS Louisiana PPO 2.76 percent of total billed charges 2.76 4.69 50% of Eligible Charges LIDOCAINE 1% 5ML AMP J2001 HCPCS 250 RC 6332349236 NDC outpatient 5 ML 5.52 4.42 BCBS Louisiana PPO 4.42 percent of total billed charges 3.04 4.69 80% of billed charge LIDOCAINE 1% 5ML AMP J2001 HCPCS 250 RC 6332349236 NDC outpatient 5 ML 5.52 4.42 Cigna Commercial PPO 3.04 percent of total billed charges 3.04 4.69 55% of Billed Charges LIDOCAINE 1% 5ML AMP J2001 HCPCS 250 RC 6332349236 NDC inpatient 5 ML 5.52 2.76 IMA of Louisiana Commercial PPO 4.69 percent of total billed charges 2.76 4.69 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 1% 5ML AMP J2001 HCPCS 250 RC 6332349236 NDC outpatient 5 ML 5.52 4.42 IMA of Louisiana Commercial PPO 4.69 percent of total billed charges 3.04 4.69 Reimbursement at 85% of billed charges BUPIVACAINE LIPOSOME 1.3% 20ML C9290 HCPCS 250 RC 6525026620 NDC inpatient 20 ML 2152.86 1076.43 BCBS Louisiana PPO 1076.43 percent of total billed charges 1076.43 1829.93 50% of Eligible Charges BUPIVACAINE LIPOSOME 1.3% 20ML C9290 HCPCS 250 RC 6525026620 NDC outpatient 20 ML 2152.86 1722.29 BCBS Louisiana PPO 1722.29 percent of total billed charges 1184.07 1829.93 80% of billed charge BUPIVACAINE LIPOSOME 1.3% 20ML C9290 HCPCS 250 RC 6525026620 NDC outpatient 20 ML 2152.86 1722.29 Cigna Commercial PPO 1184.07 percent of total billed charges 1184.07 1829.93 55% of Billed Charges BUPIVACAINE LIPOSOME 1.3% 20ML C9290 HCPCS 250 RC 6525026620 NDC inpatient 20 ML 2152.86 1076.43 IMA of Louisiana Commercial PPO 1829.93 percent of total billed charges 1076.43 1829.93 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE LIPOSOME 1.3% 20ML C9290 HCPCS 250 RC 6525026620 NDC outpatient 20 ML 2152.86 1722.29 IMA of Louisiana Commercial PPO 1829.93 percent of total billed charges 1184.07 1829.93 Reimbursement at 85% of billed charges BUPIVACAINE 0.5% W/EPI 30ML J3490 HCPCS 250 RC 6332346237 NDC inpatient 30 ML 43.32 21.66 BCBS Louisiana PPO 21.66 percent of total billed charges 21.66 36.82 50% of Eligible Charges BUPIVACAINE 0.5% W/EPI 30ML J3490 HCPCS 250 RC 6332346237 NDC outpatient 30 ML 43.32 34.66 BCBS Louisiana PPO 34.66 percent of total billed charges 23.83 36.82 80% of billed charge BUPIVACAINE 0.5% W/EPI 30ML J3490 HCPCS 250 RC 6332346237 NDC outpatient 30 ML 43.32 34.66 Cigna Commercial PPO 23.83 percent of total billed charges 23.83 36.82 55% of Billed Charges BUPIVACAINE 0.5% W/EPI 30ML J3490 HCPCS 250 RC 6332346237 NDC inpatient 30 ML 43.32 21.66 IMA of Louisiana Commercial PPO 36.82 percent of total billed charges 21.66 36.82 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.5% W/EPI 30ML J3490 HCPCS 250 RC 6332346237 NDC outpatient 30 ML 43.32 34.66 IMA of Louisiana Commercial PPO 36.82 percent of total billed charges 23.83 36.82 Reimbursement at 85% of billed charges SUCCINYLCHOLINE 20MG/ML 10ML J0330 HCPCS 250 RC 3172298131 NDC inpatient 20 ME 10.5 5.25 BCBS Louisiana PPO 5.25 percent of total billed charges 5.25 8.93 50% of Eligible Charges SUCCINYLCHOLINE 20MG/ML 10ML J0330 HCPCS 250 RC 3172298131 NDC outpatient 20 ME 10.5 8.4 BCBS Louisiana PPO 8.4 percent of total billed charges 5.78 8.93 80% of billed charge SUCCINYLCHOLINE 20MG/ML 10ML J0330 HCPCS 250 RC 3172298131 NDC outpatient 20 ME 10.5 8.4 Cigna Commercial PPO 5.78 percent of total billed charges 5.78 8.93 55% of Billed Charges SUCCINYLCHOLINE 20MG/ML 10ML J0330 HCPCS 250 RC 3172298131 NDC inpatient 20 ME 10.5 5.25 IMA of Louisiana Commercial PPO 8.93 percent of total billed charges 5.25 8.93 Inpatient Reimbursement at 85% of Billed Charges SUCCINYLCHOLINE 20MG/ML 10ML J0330 HCPCS 250 RC 3172298131 NDC outpatient 20 ME 10.5 8.4 IMA of Louisiana Commercial PPO 8.93 percent of total billed charges 5.78 8.93 Reimbursement at 85% of billed charges VASOPRESSIN INJ 20U/1ML NON-FORMULARY J3490 HCPCS 260 RC 4202316401 NDC inpatient 1 ML 74.24 37.12 BCBS Louisiana PPO 37.12 percent of total billed charges 37.12 63.1 50% of Eligible Charges VASOPRESSIN INJ 20U/1ML NON-FORMULARY J3490 HCPCS 260 RC 4202316401 NDC outpatient 1 ML 74.24 59.39 BCBS Louisiana PPO 59.39 percent of total billed charges 40.83 63.1 80% of billed charge VASOPRESSIN INJ 20U/1ML NON-FORMULARY J3490 HCPCS 260 RC 4202316401 NDC outpatient 1 ML 74.24 59.39 Cigna Commercial PPO 40.83 percent of total billed charges 40.83 63.1 55% of Billed Charges VASOPRESSIN INJ 20U/1ML NON-FORMULARY J3490 HCPCS 260 RC 4202316401 NDC inpatient 1 ML 74.24 37.12 IMA of Louisiana Commercial PPO 63.1 percent of total billed charges 37.12 63.1 Inpatient Reimbursement at 85% of Billed Charges VASOPRESSIN INJ 20U/1ML NON-FORMULARY J3490 HCPCS 260 RC 4202316401 NDC outpatient 1 ML 74.24 59.39 IMA of Louisiana Commercial PPO 63.1 percent of total billed charges 40.83 63.1 Reimbursement at 85% of billed charges WATER STERILE PF 100ML VIAL J3490 HCPCS 260 RC 0409488799 NDC inpatient 100 ML 18.48 9.24 BCBS Louisiana PPO 9.24 percent of total billed charges 9.24 15.71 50% of Eligible Charges WATER STERILE PF 100ML VIAL J3490 HCPCS 260 RC 0409488799 NDC outpatient 100 ML 18.48 14.78 BCBS Louisiana PPO 14.78 percent of total billed charges 10.16 15.71 80% of billed charge WATER STERILE PF 100ML VIAL J3490 HCPCS 260 RC 0409488799 NDC outpatient 100 ML 18.48 14.78 Cigna Commercial PPO 10.16 percent of total billed charges 10.16 15.71 55% of Billed Charges WATER STERILE PF 100ML VIAL J3490 HCPCS 260 RC 0409488799 NDC inpatient 100 ML 18.48 9.24 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 9.24 15.71 Inpatient Reimbursement at 85% of Billed Charges WATER STERILE PF 100ML VIAL J3490 HCPCS 260 RC 0409488799 NDC outpatient 100 ML 18.48 14.78 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 10.16 15.71 Reimbursement at 85% of billed charges ETOMIDATE 20MG/10ML INJ J3490 HCPCS 260 RC 5515022110 NDC inpatient 20 ME 16.2 8.1 BCBS Louisiana PPO 8.1 percent of total billed charges 8.1 13.77 50% of Eligible Charges ETOMIDATE 20MG/10ML INJ J3490 HCPCS 260 RC 5515022110 NDC outpatient 20 ME 16.2 12.96 BCBS Louisiana PPO 12.96 percent of total billed charges 8.91 13.77 80% of billed charge ETOMIDATE 20MG/10ML INJ J3490 HCPCS 260 RC 5515022110 NDC outpatient 20 ME 16.2 12.96 Cigna Commercial PPO 8.91 percent of total billed charges 8.91 13.77 55% of Billed Charges ETOMIDATE 20MG/10ML INJ J3490 HCPCS 260 RC 5515022110 NDC inpatient 20 ME 16.2 8.1 IMA of Louisiana Commercial PPO 13.77 percent of total billed charges 8.1 13.77 Inpatient Reimbursement at 85% of Billed Charges ETOMIDATE 20MG/10ML INJ J3490 HCPCS 260 RC 5515022110 NDC outpatient 20 ME 16.2 12.96 IMA of Louisiana Commercial PPO 13.77 percent of total billed charges 8.91 13.77 Reimbursement at 85% of billed charges PREMARIN 0.625 TABLET 250 RC 0046110281 NDC inpatient 0.625 ME 39.78 19.89 BCBS Louisiana PPO 19.89 percent of total billed charges 19.89 33.81 50% of Eligible Charges PREMARIN 0.625 TABLET 250 RC 0046110281 NDC outpatient 0.625 ME 39.78 31.82 BCBS Louisiana PPO 31.82 percent of total billed charges 21.88 33.81 80% of billed charge PREMARIN 0.625 TABLET 250 RC 0046110281 NDC outpatient 0.625 ME 39.78 31.82 Cigna Commercial PPO 21.88 percent of total billed charges 21.88 33.81 55% of Billed Charges PREMARIN 0.625 TABLET 250 RC 0046110281 NDC inpatient 0.625 ME 39.78 19.89 IMA of Louisiana Commercial PPO 33.81 percent of total billed charges 19.89 33.81 Inpatient Reimbursement at 85% of Billed Charges PREMARIN 0.625 TABLET 250 RC 0046110281 NDC outpatient 0.625 ME 39.78 31.82 IMA of Louisiana Commercial PPO 33.81 percent of total billed charges 21.88 33.81 Reimbursement at 85% of billed charges PREMARIN 0.625 TABLET 250 RC 0046110281 NDC outpatient 0.625 ME 39.78 31.82 Aetna Commercial PPO 21.88 percent of total billed charges 21.88 33.81 55 of billed Charges PROTONIX 40MG TABLET 250 RC 5107905120 NDC inpatient 40 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PROTONIX 40MG TABLET 250 RC 5107905120 NDC outpatient 40 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PROTONIX 40MG TABLET 250 RC 5107905120 NDC outpatient 40 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PROTONIX 40MG TABLET 250 RC 5107905120 NDC inpatient 40 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PROTONIX 40MG TABLET 250 RC 5107905120 NDC outpatient 40 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PROTONIX 40MG TABLET 250 RC 5107905120 NDC outpatient 40 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC inpatient 145 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC outpatient 145 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC outpatient 145 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC inpatient 145 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC outpatient 145 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FENOFIBRATE 145MG TABLET 250 RC 4354743109 NDC outpatient 145 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC inpatient 30 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC outpatient 30 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC outpatient 30 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC inpatient 30 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC outpatient 30 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DULOXETINE 30MG CAPSULE 250 RC 2724109803 NDC outpatient 30 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC inpatient 1 EA 962.04 481.02 BCBS Louisiana PPO 481.02 percent of total billed charges 481.02 817.73 50% of Eligible Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 BCBS Louisiana PPO 769.63 percent of total billed charges 529.12 817.73 80% of billed charge GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 Cigna Commercial PPO 529.12 percent of total billed charges 529.12 817.73 55% of Billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC inpatient 1 EA 962.04 481.02 IMA of Louisiana Commercial PPO 817.73 percent of total billed charges 481.02 817.73 Inpatient Reimbursement at 85% of Billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 IMA of Louisiana Commercial PPO 817.73 percent of total billed charges 529.12 817.73 Reimbursement at 85% of billed charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 Aetna Commercial PPO 529.12 percent of total billed charges 529.12 817.73 55 of billed Charges ALPRAZOLAM 0.5MG ODT TAB J8499 HCPCS 250 RC 4988411174 NDC inpatient 0.5 ME 8.06 4.03 BCBS Louisiana PPO 4.03 percent of total billed charges 4.03 6.85 50% of Eligible Charges ALPRAZOLAM 0.5MG ODT TAB J8499 HCPCS 250 RC 4988411174 NDC outpatient 0.5 ME 8.06 6.45 BCBS Louisiana PPO 6.45 percent of total billed charges 4.43 6.85 80% of billed charge ALPRAZOLAM 0.5MG ODT TAB J8499 HCPCS 250 RC 4988411174 NDC outpatient 0.5 ME 8.06 6.45 Cigna Commercial PPO 4.43 percent of total billed charges 4.43 6.85 55% of Billed Charges ALPRAZOLAM 0.5MG ODT TAB J8499 HCPCS 250 RC 4988411174 NDC inpatient 0.5 ME 8.06 4.03 IMA of Louisiana Commercial PPO 6.85 percent of total billed charges 4.03 6.85 Inpatient Reimbursement at 85% of Billed Charges ALPRAZOLAM 0.5MG ODT TAB J8499 HCPCS 250 RC 4988411174 NDC outpatient 0.5 ME 8.06 6.45 IMA of Louisiana Commercial PPO 6.85 percent of total billed charges 4.43 6.85 Reimbursement at 85% of billed charges LORATADINE 10MG TABLET 250 RC 5107924601 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LORATADINE 10MG TABLET 250 RC 5107924601 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LORATADINE 10MG TABLET 250 RC 5107924601 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LORATADINE 10MG TABLET 250 RC 5107924601 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LORATADINE 10MG TABLET 250 RC 5107924601 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LORATADINE 10MG TABLET 250 RC 5107924601 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ZOLPIDEM 10MG TABLET 250 RC 6586216001 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC inpatient 2.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC outpatient 2.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC outpatient 2.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC inpatient 2.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC outpatient 2.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges RAMIPRIL 2.5MG CAPSULE 250 RC 6838214501 NDC outpatient 2.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC inpatient 2 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC outpatient 2 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC outpatient 2 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC inpatient 2 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC outpatient 2 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ESTRADIOL 2MG TABLET 250 RC 0555088702 NDC outpatient 2 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges AMLODIPINE 5MG TABLET 250 RC 0904637061 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC inpatient 180 ME 1.67 0.84 BCBS Louisiana PPO 0.84 percent of total billed charges 0.84 1.42 50% of Eligible Charges DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC outpatient 180 ME 1.67 1.34 BCBS Louisiana PPO 1.34 percent of total billed charges 0.92 1.42 80% of billed charge DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC outpatient 180 ME 1.67 1.34 Cigna Commercial PPO 0.92 percent of total billed charges 0.92 1.42 55% of Billed Charges DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC inpatient 180 ME 1.67 0.84 IMA of Louisiana Commercial PPO 1.42 percent of total billed charges 0.84 1.42 Inpatient Reimbursement at 85% of Billed Charges DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC outpatient 180 ME 1.67 1.34 IMA of Louisiana Commercial PPO 1.42 percent of total billed charges 0.92 1.42 Reimbursement at 85% of billed charges DILTIAZEM CD 180MG CAPSULE 250 RC 6068720611 NDC outpatient 180 ME 1.67 1.34 Aetna Commercial PPO 0.92 percent of total billed charges 0.92 1.42 55 of billed Charges ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC inpatient 81 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC outpatient 81 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC outpatient 81 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC inpatient 81 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC outpatient 81 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ASPIRIN EC 81MG TABLET 250 RC 7733303120 NDC outpatient 81 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC inpatient 1 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC outpatient 1 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC outpatient 1 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC inpatient 1 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC outpatient 1 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BUMETANIDE 1MG TABLET 250 RC 2315590101 NDC outpatient 1 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PROPRANOLOL 10MG TAB 250 RC 6923820771 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BENICAR (OLMESARTAN) 20MG TABLET 250 RC 4354730009 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC inpatient 80 ME 4.55 2.28 BCBS Louisiana PPO 2.28 percent of total billed charges 2.28 3.87 50% of Eligible Charges SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC outpatient 80 ME 4.55 3.64 BCBS Louisiana PPO 3.64 percent of total billed charges 2.5 3.87 80% of billed charge SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC outpatient 80 ME 4.55 3.64 Cigna Commercial PPO 2.5 percent of total billed charges 2.5 3.87 55% of Billed Charges SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC inpatient 80 ME 4.55 2.28 IMA of Louisiana Commercial PPO 3.87 percent of total billed charges 2.28 3.87 Inpatient Reimbursement at 85% of Billed Charges SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC outpatient 80 ME 4.55 3.64 IMA of Louisiana Commercial PPO 3.87 percent of total billed charges 2.5 3.87 Reimbursement at 85% of billed charges SOTALOL HCL 80MG TABLET 250 RC 0904714361 NDC outpatient 80 ME 4.55 3.64 Aetna Commercial PPO 2.5 percent of total billed charges 2.5 3.87 55 of billed Charges FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FUROSEMIDE 20MG TABLET 250 RC 6498056201 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC inpatient 4 ME 2.44 1.22 BCBS Louisiana PPO 1.22 percent of total billed charges 1.22 2.07 50% of Eligible Charges TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC outpatient 4 ME 2.44 1.95 BCBS Louisiana PPO 1.95 percent of total billed charges 1.34 2.07 80% of billed charge TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC outpatient 4 ME 2.44 1.95 Cigna Commercial PPO 1.34 percent of total billed charges 1.34 2.07 55% of Billed Charges TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC inpatient 4 ME 2.44 1.22 IMA of Louisiana Commercial PPO 2.07 percent of total billed charges 1.22 2.07 Inpatient Reimbursement at 85% of Billed Charges TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC outpatient 4 ME 2.44 1.95 IMA of Louisiana Commercial PPO 2.07 percent of total billed charges 1.34 2.07 Reimbursement at 85% of billed charges TIZANIDINE 4MG TABLET 250 RC 0904641861 NDC outpatient 4 ME 2.44 1.95 Aetna Commercial PPO 1.34 percent of total billed charges 1.34 2.07 55 of billed Charges ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC inpatient 325 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC outpatient 325 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC outpatient 325 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC inpatient 325 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC outpatient 325 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ASPIRIN EC 325MG TABLET 250 RC 6961801501 NDC outpatient 325 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC inpatient 500 ME 1.34 0.67 BCBS Louisiana PPO 0.67 percent of total billed charges 0.67 1.14 50% of Eligible Charges CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC outpatient 500 ME 1.34 1.07 BCBS Louisiana PPO 1.07 percent of total billed charges 0.74 1.14 80% of billed charge CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC outpatient 500 ME 1.34 1.07 Cigna Commercial PPO 0.74 percent of total billed charges 0.74 1.14 55% of Billed Charges CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC inpatient 500 ME 1.34 0.67 IMA of Louisiana Commercial PPO 1.14 percent of total billed charges 0.67 1.14 Inpatient Reimbursement at 85% of Billed Charges CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC outpatient 500 ME 1.34 1.07 IMA of Louisiana Commercial PPO 1.14 percent of total billed charges 0.74 1.14 Reimbursement at 85% of billed charges CIPROFLOXACIN 500MG TABLET 250 RC 0904708361 NDC outpatient 500 ME 1.34 1.07 Aetna Commercial PPO 0.74 percent of total billed charges 0.74 1.14 55 of billed Charges AMIODARONE 200MG TABLET 250 RC 6068743701 NDC inpatient 200 ME 1.18 0.59 BCBS Louisiana PPO 0.59 percent of total billed charges 0.59 1 50% of Eligible Charges AMIODARONE 200MG TABLET 250 RC 6068743701 NDC outpatient 200 ME 1.18 0.94 BCBS Louisiana PPO 0.94 percent of total billed charges 0.65 1 80% of billed charge AMIODARONE 200MG TABLET 250 RC 6068743701 NDC outpatient 200 ME 1.18 0.94 Cigna Commercial PPO 0.65 percent of total billed charges 0.65 1 55% of Billed Charges AMIODARONE 200MG TABLET 250 RC 6068743701 NDC inpatient 200 ME 1.18 0.59 IMA of Louisiana Commercial PPO 1 percent of total billed charges 0.59 1 Inpatient Reimbursement at 85% of Billed Charges AMIODARONE 200MG TABLET 250 RC 6068743701 NDC outpatient 200 ME 1.18 0.94 IMA of Louisiana Commercial PPO 1 percent of total billed charges 0.65 1 Reimbursement at 85% of billed charges AMIODARONE 200MG TABLET 250 RC 6068743701 NDC outpatient 200 ME 1.18 0.94 Aetna Commercial PPO 0.65 percent of total billed charges 0.65 1 55 of billed Charges HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC inpatient 0.125 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC outpatient 0.125 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC outpatient 0.125 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC inpatient 0.125 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC outpatient 0.125 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HYOSCYAMINE SL 0.125MG TABLET 250 RC 4219233901 NDC outpatient 0.125 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC inpatient 100 ME 7.14 3.57 BCBS Louisiana PPO 3.57 percent of total billed charges 3.57 6.07 50% of Eligible Charges BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC outpatient 100 ME 7.14 5.71 BCBS Louisiana PPO 5.71 percent of total billed charges 3.93 6.07 80% of billed charge BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC outpatient 100 ME 7.14 5.71 Cigna Commercial PPO 3.93 percent of total billed charges 3.93 6.07 55% of Billed Charges BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC inpatient 100 ME 7.14 3.57 IMA of Louisiana Commercial PPO 6.07 percent of total billed charges 3.57 6.07 Inpatient Reimbursement at 85% of Billed Charges BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC outpatient 100 ME 7.14 5.71 IMA of Louisiana Commercial PPO 6.07 percent of total billed charges 3.93 6.07 Reimbursement at 85% of billed charges BUPROPION HCL 100MG TABLET 250 RC 6068735111 NDC outpatient 100 ME 7.14 5.71 Aetna Commercial PPO 3.93 percent of total billed charges 3.93 6.07 55 of billed Charges CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC inpatient 600 ME 12 6 BCBS Louisiana PPO 6 percent of total billed charges 6 10.2 50% of Eligible Charges CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC outpatient 600 ME 12 9.6 BCBS Louisiana PPO 9.6 percent of total billed charges 6.6 10.2 80% of billed charge CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC outpatient 600 ME 12 9.6 Cigna Commercial PPO 6.6 percent of total billed charges 6.6 10.2 55% of Billed Charges CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC inpatient 600 ME 12 6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6 10.2 Inpatient Reimbursement at 85% of Billed Charges CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC outpatient 600 ME 12 9.6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6.6 10.2 Reimbursement at 85% of billed charges CLINDAMYCIN 600MG/4ML VIAL 260 RC 0009077526 NDC outpatient 600 ME 12 9.6 Aetna Commercial PPO 6.6 percent of total billed charges 6.6 10.2 55 of billed Charges BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC inpatient 75 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC outpatient 75 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC outpatient 75 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC inpatient 75 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC outpatient 75 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BUPROPION HCL 75MG TAB 250 RC 6050501581 NDC outpatient 75 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC inpatient 3 ML 299.8 149.9 BCBS Louisiana PPO 149.9 percent of total billed charges 149.9 254.83 50% of Eligible Charges HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC outpatient 3 ML 299.8 239.84 BCBS Louisiana PPO 239.84 percent of total billed charges 164.89 254.83 80% of billed charge HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC outpatient 3 ML 299.8 239.84 Cigna Commercial PPO 164.89 percent of total billed charges 164.89 254.83 55% of Billed Charges HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC inpatient 3 ML 299.8 149.9 IMA of Louisiana Commercial PPO 254.83 percent of total billed charges 149.9 254.83 Inpatient Reimbursement at 85% of Billed Charges HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC outpatient 3 ML 299.8 239.84 IMA of Louisiana Commercial PPO 254.83 percent of total billed charges 164.89 254.83 Reimbursement at 85% of billed charges HUMULIN 70/30 100U/ML 3ML SYRINGE 250 RC 0169300415 NDC outpatient 3 ML 299.8 239.84 Aetna Commercial PPO 164.89 percent of total billed charges 164.89 254.83 55 of billed Charges RIFAMPIN 300MG CAP 250 RC 6068758601 NDC inpatient 300 ME 9.3 4.65 BCBS Louisiana PPO 4.65 percent of total billed charges 4.65 7.91 50% of Eligible Charges RIFAMPIN 300MG CAP 250 RC 6068758601 NDC outpatient 300 ME 9.3 7.44 BCBS Louisiana PPO 7.44 percent of total billed charges 5.12 7.91 80% of billed charge RIFAMPIN 300MG CAP 250 RC 6068758601 NDC outpatient 300 ME 9.3 7.44 Cigna Commercial PPO 5.12 percent of total billed charges 5.12 7.91 55% of Billed Charges RIFAMPIN 300MG CAP 250 RC 6068758601 NDC inpatient 300 ME 9.3 4.65 IMA of Louisiana Commercial PPO 7.91 percent of total billed charges 4.65 7.91 Inpatient Reimbursement at 85% of Billed Charges RIFAMPIN 300MG CAP 250 RC 6068758601 NDC outpatient 300 ME 9.3 7.44 IMA of Louisiana Commercial PPO 7.91 percent of total billed charges 5.12 7.91 Reimbursement at 85% of billed charges RIFAMPIN 300MG CAP 250 RC 6068758601 NDC outpatient 300 ME 9.3 7.44 Aetna Commercial PPO 5.12 percent of total billed charges 5.12 7.91 55 of billed Charges SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC inpatient 100 ML 8.57 4.29 BCBS Louisiana PPO 4.29 percent of total billed charges 4.29 7.28 50% of Eligible Charges SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC outpatient 100 ML 8.57 6.86 BCBS Louisiana PPO 6.86 percent of total billed charges 4.71 7.28 80% of billed charge SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC outpatient 100 ML 8.57 6.86 Cigna Commercial PPO 4.71 percent of total billed charges 4.71 7.28 55% of Billed Charges SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC inpatient 100 ML 8.57 4.29 IMA of Louisiana Commercial PPO 7.28 percent of total billed charges 4.29 7.28 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC outpatient 100 ML 8.57 6.86 IMA of Louisiana Commercial PPO 7.28 percent of total billed charges 4.71 7.28 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 100ML ADD-BAG 260 RC 0409710167 NDC outpatient 100 ML 8.57 6.86 Aetna Commercial PPO 4.71 percent of total billed charges 4.71 7.28 55 of billed Charges LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC inpatient 10 ME 1.92 0.96 BCBS Louisiana PPO 0.96 percent of total billed charges 0.96 1.63 50% of Eligible Charges LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC outpatient 10 ME 1.92 1.54 BCBS Louisiana PPO 1.54 percent of total billed charges 1.06 1.63 80% of billed charge LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC outpatient 10 ME 1.92 1.54 Cigna Commercial PPO 1.06 percent of total billed charges 1.06 1.63 55% of Billed Charges LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC inpatient 10 ME 1.92 0.96 IMA of Louisiana Commercial PPO 1.63 percent of total billed charges 0.96 1.63 Inpatient Reimbursement at 85% of Billed Charges LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC outpatient 10 ME 1.92 1.54 IMA of Louisiana Commercial PPO 1.63 percent of total billed charges 1.06 1.63 Reimbursement at 85% of billed charges LEFLUNOMIDE 10MG TABLET 250 RC 6050525021 NDC outpatient 10 ME 1.92 1.54 Aetna Commercial PPO 1.06 percent of total billed charges 1.06 1.63 55 of billed Charges MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC inpatient 15 ME 3.93 1.97 BCBS Louisiana PPO 1.97 percent of total billed charges 1.97 3.34 50% of Eligible Charges MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC outpatient 15 ME 3.93 3.14 BCBS Louisiana PPO 3.14 percent of total billed charges 2.16 3.34 80% of billed charge MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC outpatient 15 ME 3.93 3.14 Cigna Commercial PPO 2.16 percent of total billed charges 2.16 3.34 55% of Billed Charges MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC inpatient 15 ME 3.93 1.97 IMA of Louisiana Commercial PPO 3.34 percent of total billed charges 1.97 3.34 Inpatient Reimbursement at 85% of Billed Charges MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC outpatient 15 ME 3.93 3.14 IMA of Louisiana Commercial PPO 3.34 percent of total billed charges 2.16 3.34 Reimbursement at 85% of billed charges MORPHINE SULF ER 15MG TABLET 250 RC 6808415701 NDC outpatient 15 ME 3.93 3.14 Aetna Commercial PPO 2.16 percent of total billed charges 2.16 3.34 55 of billed Charges OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC inpatient 5 ME 2.19 1.1 BCBS Louisiana PPO 1.1 percent of total billed charges 1.1 1.86 50% of Eligible Charges OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC outpatient 5 ME 2.19 1.75 BCBS Louisiana PPO 1.75 percent of total billed charges 1.2 1.86 80% of billed charge OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC outpatient 5 ME 2.19 1.75 Cigna Commercial PPO 1.2 percent of total billed charges 1.2 1.86 55% of Billed Charges OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC inpatient 5 ME 2.19 1.1 IMA of Louisiana Commercial PPO 1.86 percent of total billed charges 1.1 1.86 Inpatient Reimbursement at 85% of Billed Charges OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC outpatient 5 ME 2.19 1.75 IMA of Louisiana Commercial PPO 1.86 percent of total billed charges 1.2 1.86 Reimbursement at 85% of billed charges OXYCODONE IR 5MG TABLET 250 RC 0406055223 NDC outpatient 5 ME 2.19 1.75 Aetna Commercial PPO 1.2 percent of total billed charges 1.2 1.86 55 of billed Charges PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC inpatient 25 ME 2.23 1.12 BCBS Louisiana PPO 1.12 percent of total billed charges 1.12 1.9 50% of Eligible Charges PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC outpatient 25 ME 2.23 1.78 BCBS Louisiana PPO 1.78 percent of total billed charges 1.23 1.9 80% of billed charge PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC outpatient 25 ME 2.23 1.78 Cigna Commercial PPO 1.23 percent of total billed charges 1.23 1.9 55% of Billed Charges PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC inpatient 25 ME 2.23 1.12 IMA of Louisiana Commercial PPO 1.9 percent of total billed charges 1.12 1.9 Inpatient Reimbursement at 85% of Billed Charges PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC outpatient 25 ME 2.23 1.78 IMA of Louisiana Commercial PPO 1.9 percent of total billed charges 1.23 1.9 Reimbursement at 85% of billed charges PREGABALIN 25MG CAPSULE 250 RC 6068747311 NDC outpatient 25 ME 2.23 1.78 Aetna Commercial PPO 1.23 percent of total billed charges 1.23 1.9 55 of billed Charges ACETAMINOPHEN CAPLET : 500MG J8499 HCPCS 250 RC 5058044936 NDC inpatient 500 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ACETAMINOPHEN CAPLET : 500MG J8499 HCPCS 250 RC 5058044936 NDC outpatient 500 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ACETAMINOPHEN CAPLET : 500MG J8499 HCPCS 250 RC 5058044936 NDC outpatient 500 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ACETAMINOPHEN CAPLET : 500MG J8499 HCPCS 250 RC 5058044936 NDC inpatient 500 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ACETAMINOPHEN CAPLET : 500MG J8499 HCPCS 250 RC 5058044936 NDC outpatient 500 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HUMALOG 75/25 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0002879759 NDC inpatient 3 ML 183.3 91.65 BCBS Louisiana PPO 91.65 percent of total billed charges 91.65 155.81 50% of Eligible Charges HUMALOG 75/25 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0002879759 NDC outpatient 3 ML 183.3 146.64 BCBS Louisiana PPO 146.64 percent of total billed charges 100.82 155.81 80% of billed charge HUMALOG 75/25 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0002879759 NDC outpatient 3 ML 183.3 146.64 Cigna Commercial PPO 100.82 percent of total billed charges 100.82 155.81 55% of Billed Charges HUMALOG 75/25 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0002879759 NDC inpatient 3 ML 183.3 91.65 IMA of Louisiana Commercial PPO 155.81 percent of total billed charges 91.65 155.81 Inpatient Reimbursement at 85% of Billed Charges HUMALOG 75/25 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0002879759 NDC outpatient 3 ML 183.3 146.64 IMA of Louisiana Commercial PPO 155.81 percent of total billed charges 100.82 155.81 Reimbursement at 85% of billed charges POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC inpatient 10 UN 1.14 0.57 BCBS Louisiana PPO 0.57 percent of total billed charges 0.57 0.97 50% of Eligible Charges POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC outpatient 10 UN 1.14 0.91 BCBS Louisiana PPO 0.91 percent of total billed charges 0.63 0.97 80% of billed charge POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC outpatient 10 UN 1.14 0.91 Cigna Commercial PPO 0.63 percent of total billed charges 0.63 0.97 55% of Billed Charges POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC inpatient 10 UN 1.14 0.57 IMA of Louisiana Commercial PPO 0.97 percent of total billed charges 0.57 0.97 Inpatient Reimbursement at 85% of Billed Charges POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC outpatient 10 UN 1.14 0.91 IMA of Louisiana Commercial PPO 0.97 percent of total billed charges 0.63 0.97 Reimbursement at 85% of billed charges POTASSIUM CITRATE 10MEQ TABLET 250 RC 6838253701 NDC outpatient 10 UN 1.14 0.91 Aetna Commercial PPO 0.63 percent of total billed charges 0.63 0.97 55 of billed Charges GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC inpatient 0.2 ME 5.38 2.69 BCBS Louisiana PPO 2.69 percent of total billed charges 2.69 4.57 50% of Eligible Charges GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC outpatient 0.2 ME 5.38 4.3 BCBS Louisiana PPO 4.3 percent of total billed charges 2.96 4.57 80% of billed charge GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC outpatient 0.2 ME 5.38 4.3 Cigna Commercial PPO 2.96 percent of total billed charges 2.96 4.57 55% of Billed Charges GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC inpatient 0.2 ME 5.38 2.69 IMA of Louisiana Commercial PPO 4.57 percent of total billed charges 2.69 4.57 Inpatient Reimbursement at 85% of Billed Charges GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC outpatient 0.2 ME 5.38 4.3 IMA of Louisiana Commercial PPO 4.57 percent of total billed charges 2.96 4.57 Reimbursement at 85% of billed charges GLYCOPYRROLATE 0.2MG/ML 2ML 260 RC 7070001662 NDC outpatient 0.2 ME 5.38 4.3 Aetna Commercial PPO 2.96 percent of total billed charges 2.96 4.57 55 of billed Charges BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BYSTOLIC 5MG TABLET 250 RC 4354752509 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC inpatient 1 EA 3.06 1.53 BCBS Louisiana PPO 1.53 percent of total billed charges 1.53 2.6 50% of Eligible Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 BCBS Louisiana PPO 2.45 percent of total billed charges 1.68 2.6 80% of billed charge K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 Cigna Commercial PPO 1.68 percent of total billed charges 1.68 2.6 55% of Billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC inpatient 1 EA 3.06 1.53 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.53 2.6 Inpatient Reimbursement at 85% of Billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.68 2.6 Reimbursement at 85% of billed charges NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC inpatient 5 ML 5 2.5 BCBS Louisiana PPO 2.5 percent of total billed charges 2.5 4.25 50% of Eligible Charges NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC outpatient 5 ML 5 4 BCBS Louisiana PPO 4 percent of total billed charges 2.75 4.25 80% of billed charge NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC outpatient 5 ML 5 4 Cigna Commercial PPO 2.75 percent of total billed charges 2.75 4.25 55% of Billed Charges NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC inpatient 5 ML 5 2.5 IMA of Louisiana Commercial PPO 4.25 percent of total billed charges 2.5 4.25 Inpatient Reimbursement at 85% of Billed Charges NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC outpatient 5 ML 5 4 IMA of Louisiana Commercial PPO 4.25 percent of total billed charges 2.75 4.25 Reimbursement at 85% of billed charges NYSTATIN 100000U/ML 5ML SUSPENSION 250 RC 0121086850 NDC outpatient 5 ML 5 4 Aetna Commercial PPO 2.75 percent of total billed charges 2.75 4.25 55 of billed Charges SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC inpatient 2 ML 823.33 411.67 BCBS Louisiana PPO 411.67 percent of total billed charges 411.67 699.83 50% of Eligible Charges SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC outpatient 2 ML 823.33 658.66 BCBS Louisiana PPO 658.66 percent of total billed charges 452.83 699.83 80% of billed charge SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC outpatient 2 ML 823.33 658.66 Cigna Commercial PPO 452.83 percent of total billed charges 452.83 699.83 55% of Billed Charges SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC inpatient 2 ML 823.33 411.67 IMA of Louisiana Commercial PPO 699.83 percent of total billed charges 411.67 699.83 Inpatient Reimbursement at 85% of Billed Charges SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC outpatient 2 ML 823.33 658.66 IMA of Louisiana Commercial PPO 699.83 percent of total billed charges 452.83 699.83 Reimbursement at 85% of billed charges SUGAMMADEX 100MG/ML 2ML VIAL 250 RC 0006542312 NDC outpatient 2 ML 823.33 658.66 Aetna Commercial PPO 452.83 percent of total billed charges 452.83 699.83 55 of billed Charges METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC inpatient 125 ME 44.64 22.32 BCBS Louisiana PPO 22.32 percent of total billed charges 22.32 37.94 50% of Eligible Charges METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC outpatient 125 ME 44.64 35.71 BCBS Louisiana PPO 35.71 percent of total billed charges 24.55 37.94 80% of billed charge METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC outpatient 125 ME 44.64 35.71 Cigna Commercial PPO 24.55 percent of total billed charges 24.55 37.94 55% of Billed Charges METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC inpatient 125 ME 44.64 22.32 IMA of Louisiana Commercial PPO 37.94 percent of total billed charges 22.32 37.94 Inpatient Reimbursement at 85% of Billed Charges METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC outpatient 125 ME 44.64 35.71 IMA of Louisiana Commercial PPO 37.94 percent of total billed charges 24.55 37.94 Reimbursement at 85% of billed charges METHYLPREDNISOLONE SUCC 125MG/ML 2MLINJ. 250 RC 0009004725 NDC outpatient 125 ME 44.64 35.71 Aetna Commercial PPO 24.55 percent of total billed charges 24.55 37.94 55 of billed Charges RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC inpatient 500 ME 6.62 3.31 BCBS Louisiana PPO 3.31 percent of total billed charges 3.31 5.63 50% of Eligible Charges RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC outpatient 500 ME 6.62 5.3 BCBS Louisiana PPO 5.3 percent of total billed charges 3.64 5.63 80% of billed charge RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC outpatient 500 ME 6.62 5.3 Cigna Commercial PPO 3.64 percent of total billed charges 3.64 5.63 55% of Billed Charges RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC inpatient 500 ME 6.62 3.31 IMA of Louisiana Commercial PPO 5.63 percent of total billed charges 3.31 5.63 Inpatient Reimbursement at 85% of Billed Charges RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC outpatient 500 ME 6.62 5.3 IMA of Louisiana Commercial PPO 5.63 percent of total billed charges 3.64 5.63 Reimbursement at 85% of billed charges RANOLAZINE 500MG ER TABLET 250 RC 5026872215 NDC outpatient 500 ME 6.62 5.3 Aetna Commercial PPO 3.64 percent of total billed charges 3.64 5.63 55 of billed Charges RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges RISPERDAL 0.5MG TAB NON-FORMULARY 250 RC 5045830250 NDC outpatient 0.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC inpatient 250 ML 244.48 122.24 BCBS Louisiana PPO 122.24 percent of total billed charges 122.24 207.81 50% of Eligible Charges ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC outpatient 250 ML 244.48 195.58 BCBS Louisiana PPO 195.58 percent of total billed charges 134.46 207.81 80% of billed charge ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC outpatient 250 ML 244.48 195.58 Cigna Commercial PPO 134.46 percent of total billed charges 134.46 207.81 55% of Billed Charges ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC inpatient 250 ML 244.48 122.24 IMA of Louisiana Commercial PPO 207.81 percent of total billed charges 122.24 207.81 Inpatient Reimbursement at 85% of Billed Charges ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC outpatient 250 ML 244.48 195.58 IMA of Louisiana Commercial PPO 207.81 percent of total billed charges 134.46 207.81 Reimbursement at 85% of billed charges ALBUMIN 5% 250ML IV 260 RC 6420825101 NDC outpatient 250 ML 244.48 195.58 Aetna Commercial PPO 134.46 percent of total billed charges 134.46 207.81 55 of billed Charges ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC inpatient 40 ME 13.47 6.74 BCBS Louisiana PPO 6.74 percent of total billed charges 6.74 11.45 50% of Eligible Charges ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC outpatient 40 ME 13.47 10.78 BCBS Louisiana PPO 10.78 percent of total billed charges 7.41 11.45 80% of billed charge ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC outpatient 40 ME 13.47 10.78 Cigna Commercial PPO 7.41 percent of total billed charges 7.41 11.45 55% of Billed Charges ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC inpatient 40 ME 13.47 6.74 IMA of Louisiana Commercial PPO 11.45 percent of total billed charges 6.74 11.45 Inpatient Reimbursement at 85% of Billed Charges ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC outpatient 40 ME 13.47 10.78 IMA of Louisiana Commercial PPO 11.45 percent of total billed charges 7.41 11.45 Reimbursement at 85% of billed charges ENOXAPARIN 40MG/0.4ML INJ. 250 RC 0781322402 NDC outpatient 40 ME 13.47 10.78 Aetna Commercial PPO 7.41 percent of total billed charges 7.41 11.45 55 of billed Charges HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC inpatient 325 ME 3.53 1.77 BCBS Louisiana PPO 1.77 percent of total billed charges 1.77 3 50% of Eligible Charges HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC outpatient 325 ME 3.53 2.82 BCBS Louisiana PPO 2.82 percent of total billed charges 1.94 3 80% of billed charge HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC outpatient 325 ME 3.53 2.82 Cigna Commercial PPO 1.94 percent of total billed charges 1.94 3 55% of Billed Charges HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC inpatient 325 ME 3.53 1.77 IMA of Louisiana Commercial PPO 3 percent of total billed charges 1.77 3 Inpatient Reimbursement at 85% of Billed Charges HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC outpatient 325 ME 3.53 2.82 IMA of Louisiana Commercial PPO 3 percent of total billed charges 1.94 3 Reimbursement at 85% of billed charges HYDROCODONE/ACET 7.5/325MG TABLET 250 RC 6068740701 NDC outpatient 325 ME 3.53 2.82 Aetna Commercial PPO 1.94 percent of total billed charges 1.94 3 55 of billed Charges LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC inpatient 5 ME 38.64 19.32 BCBS Louisiana PPO 19.32 percent of total billed charges 19.32 32.84 50% of Eligible Charges LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC outpatient 5 ME 38.64 30.91 BCBS Louisiana PPO 30.91 percent of total billed charges 21.25 32.84 80% of billed charge LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC outpatient 5 ME 38.64 30.91 Cigna Commercial PPO 21.25 percent of total billed charges 21.25 32.84 55% of Billed Charges LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC inpatient 5 ME 38.64 19.32 IMA of Louisiana Commercial PPO 32.84 percent of total billed charges 19.32 32.84 Inpatient Reimbursement at 85% of Billed Charges LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC outpatient 5 ME 38.64 30.91 IMA of Louisiana Commercial PPO 32.84 percent of total billed charges 21.25 32.84 Reimbursement at 85% of billed charges LABETALOL 5MG/ML 4ML INJECTION 250 RC 0409233934 NDC outpatient 5 ME 38.64 30.91 Aetna Commercial PPO 21.25 percent of total billed charges 21.25 32.84 55 of billed Charges RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC inpatient 5 ML 9.18 4.59 BCBS Louisiana PPO 4.59 percent of total billed charges 4.59 7.8 50% of Eligible Charges RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC outpatient 5 ML 9.18 7.34 BCBS Louisiana PPO 7.34 percent of total billed charges 5.05 7.8 80% of billed charge RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC outpatient 5 ML 9.18 7.34 Cigna Commercial PPO 5.05 percent of total billed charges 5.05 7.8 55% of Billed Charges RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC inpatient 5 ML 9.18 4.59 IMA of Louisiana Commercial PPO 7.8 percent of total billed charges 4.59 7.8 Inpatient Reimbursement at 85% of Billed Charges RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC outpatient 5 ML 9.18 7.34 IMA of Louisiana Commercial PPO 7.8 percent of total billed charges 5.05 7.8 Reimbursement at 85% of billed charges RACEMIC EPINEPHRINE 2.25% SOLN 0.5ML UD 250 RC 0487278401 NDC outpatient 5 ML 9.18 7.34 Aetna Commercial PPO 5.05 percent of total billed charges 5.05 7.8 55 of billed Charges MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC inpatient 15 ME 3.87 1.94 BCBS Louisiana PPO 1.94 percent of total billed charges 1.94 3.29 50% of Eligible Charges MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC outpatient 15 ME 3.87 3.1 BCBS Louisiana PPO 3.1 percent of total billed charges 2.13 3.29 80% of billed charge MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC outpatient 15 ME 3.87 3.1 Cigna Commercial PPO 2.13 percent of total billed charges 2.13 3.29 55% of Billed Charges MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC inpatient 15 ME 3.87 1.94 IMA of Louisiana Commercial PPO 3.29 percent of total billed charges 1.94 3.29 Inpatient Reimbursement at 85% of Billed Charges MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC outpatient 15 ME 3.87 3.1 IMA of Louisiana Commercial PPO 3.29 percent of total billed charges 2.13 3.29 Reimbursement at 85% of billed charges MORPHINE SULF IR 15MG TABLET 250 RC 0054023524 NDC outpatient 15 ME 3.87 3.1 Aetna Commercial PPO 2.13 percent of total billed charges 2.13 3.29 55 of billed Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC inpatient 1 EA 5.33 2.67 BCBS Louisiana PPO 2.67 percent of total billed charges 2.67 4.53 50% of Eligible Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 BCBS Louisiana PPO 4.26 percent of total billed charges 2.93 4.53 80% of billed charge MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 Cigna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55% of Billed Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC inpatient 1 EA 5.33 2.67 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.67 4.53 Inpatient Reimbursement at 85% of Billed Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.93 4.53 Reimbursement at 85% of billed charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 Aetna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55 of billed Charges MELATONIN 5MG TABLET 250 RC 3076815745 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges MELATONIN 5MG TABLET 250 RC 3076815745 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge MELATONIN 5MG TABLET 250 RC 3076815745 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges MELATONIN 5MG TABLET 250 RC 3076815745 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges MELATONIN 5MG TABLET 250 RC 3076815745 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MELATONIN 5MG TABLET 250 RC 3076815745 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC inpatient 400 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC outpatient 400 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC outpatient 400 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC inpatient 400 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC outpatient 400 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GUAIFENESIN 400MG TABLET 250 RC 6961806106 NDC outpatient 400 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC inpatient 20 ME 3.08 1.54 BCBS Louisiana PPO 1.54 percent of total billed charges 1.54 2.62 50% of Eligible Charges HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC outpatient 20 ME 3.08 2.46 BCBS Louisiana PPO 2.46 percent of total billed charges 1.69 2.62 80% of billed charge HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC outpatient 20 ME 3.08 2.46 Cigna Commercial PPO 1.69 percent of total billed charges 1.69 2.62 55% of Billed Charges HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC inpatient 20 ME 3.08 1.54 IMA of Louisiana Commercial PPO 2.62 percent of total billed charges 1.54 2.62 Inpatient Reimbursement at 85% of Billed Charges HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC outpatient 20 ME 3.08 2.46 IMA of Louisiana Commercial PPO 2.62 percent of total billed charges 1.69 2.62 Reimbursement at 85% of billed charges HYDROCORTISONE 10MG TABS NON-FORMULARY 250 RC 5965141501 NDC outpatient 20 ME 3.08 2.46 Aetna Commercial PPO 1.69 percent of total billed charges 1.69 2.62 55 of billed Charges APIXABAN 5MG TABLET J8499 HCPCS 250 RC 0003089431 NDC inpatient 5 ME 33.18 16.59 BCBS Louisiana PPO 16.59 percent of total billed charges 16.59 28.2 50% of Eligible Charges APIXABAN 5MG TABLET J8499 HCPCS 250 RC 0003089431 NDC outpatient 5 ME 33.18 26.54 BCBS Louisiana PPO 26.54 percent of total billed charges 18.25 28.2 80% of billed charge APIXABAN 5MG TABLET J8499 HCPCS 250 RC 0003089431 NDC outpatient 5 ME 33.18 26.54 Cigna Commercial PPO 18.25 percent of total billed charges 18.25 28.2 55% of Billed Charges APIXABAN 5MG TABLET J8499 HCPCS 250 RC 0003089431 NDC inpatient 5 ME 33.18 16.59 IMA of Louisiana Commercial PPO 28.2 percent of total billed charges 16.59 28.2 Inpatient Reimbursement at 85% of Billed Charges APIXABAN 5MG TABLET J8499 HCPCS 250 RC 0003089431 NDC outpatient 5 ME 33.18 26.54 IMA of Louisiana Commercial PPO 28.2 percent of total billed charges 18.25 28.2 Reimbursement at 85% of billed charges OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC inpatient 5 ME 7.36 3.68 BCBS Louisiana PPO 3.68 percent of total billed charges 3.68 6.26 50% of Eligible Charges OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC outpatient 5 ME 7.36 5.89 BCBS Louisiana PPO 5.89 percent of total billed charges 4.05 6.26 80% of billed charge OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC outpatient 5 ME 7.36 5.89 Cigna Commercial PPO 4.05 percent of total billed charges 4.05 6.26 55% of Billed Charges OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC inpatient 5 ME 7.36 3.68 IMA of Louisiana Commercial PPO 6.26 percent of total billed charges 3.68 6.26 Inpatient Reimbursement at 85% of Billed Charges OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC outpatient 5 ME 7.36 5.89 IMA of Louisiana Commercial PPO 6.26 percent of total billed charges 4.05 6.26 Reimbursement at 85% of billed charges OXYBUTYNIN ER 5MG TABLET 250 RC 6808448001 NDC outpatient 5 ME 7.36 5.89 Aetna Commercial PPO 4.05 percent of total billed charges 4.05 6.26 55 of billed Charges MOVANTIK 25MG TABLET 250 RC 5570038330 NDC inpatient 25 ME 81.45 40.73 BCBS Louisiana PPO 40.73 percent of total billed charges 40.73 69.23 50% of Eligible Charges MOVANTIK 25MG TABLET 250 RC 5570038330 NDC outpatient 25 ME 81.45 65.16 BCBS Louisiana PPO 65.16 percent of total billed charges 44.8 69.23 80% of billed charge MOVANTIK 25MG TABLET 250 RC 5570038330 NDC outpatient 25 ME 81.45 65.16 Cigna Commercial PPO 44.8 percent of total billed charges 44.8 69.23 55% of Billed Charges MOVANTIK 25MG TABLET 250 RC 5570038330 NDC inpatient 25 ME 81.45 40.73 IMA of Louisiana Commercial PPO 69.23 percent of total billed charges 40.73 69.23 Inpatient Reimbursement at 85% of Billed Charges MOVANTIK 25MG TABLET 250 RC 5570038330 NDC outpatient 25 ME 81.45 65.16 IMA of Louisiana Commercial PPO 69.23 percent of total billed charges 44.8 69.23 Reimbursement at 85% of billed charges MOVANTIK 25MG TABLET 250 RC 5570038330 NDC outpatient 25 ME 81.45 65.16 Aetna Commercial PPO 44.8 percent of total billed charges 44.8 69.23 55 of billed Charges BICEPS TENODESIS 29828 CPT 360 RC inpatient 9390.75 4695.38 BCBS Louisiana PPO 4695.38 percent of total billed charges 4695.38 7982.14 50% of Eligible Charges BICEPS TENODESIS 29828 CPT 360 RC outpatient 9390.75 7512.6 BCBS Louisiana PPO 7512.6 percent of total billed charges 1300 7982.14 80% of billed charges BICEPS TENODESIS 29828 CPT 360 RC outpatient 9390.75 7512.6 Cigna Commercial PPO 5164.91 percent of total billed charges 1300 7982.14 55% of Billed Charges BICEPS TENODESIS 29828 CPT 360 RC inpatient 9390.75 4695.38 IMA of Louisiana Commercial PPO 7982.14 percent of total billed charges 4695.38 7982.14 Inpatient Reimbursement at 85% of Billed Charges BICEPS TENODESIS 29828 CPT 360 RC outpatient 9390.75 7512.6 IMA of Louisiana Commercial PPO 7982.14 percent of total billed charges 1300 7982.14 Reimbursement at 85% of billed charges BICEPS TENODESIS 29828 CPT 360 RC outpatient 9390.75 7512.6 Aetna Commercial PPO 1300 fee schedule 1300 7982.14 Case Rate ARTHROSCOPY OF JOINT 29999 CPT 360 RC inpatient 537.25 268.63 BCBS Louisiana PPO 268.63 percent of total billed charges 268.63 456.66 50% of Eligible Charges ARTHROSCOPY OF JOINT 29999 CPT 360 RC outpatient 537.25 429.8 BCBS Louisiana PPO 429.8 percent of total billed charges 295.49 1300 80% of billed charges ARTHROSCOPY OF JOINT 29999 CPT 360 RC outpatient 537.25 429.8 Cigna Commercial PPO 295.49 percent of total billed charges 295.49 1300 55% of Billed Charges ARTHROSCOPY OF JOINT 29999 CPT 360 RC inpatient 537.25 268.63 IMA of Louisiana Commercial PPO 456.66 percent of total billed charges 268.63 456.66 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY OF JOINT 29999 CPT 360 RC outpatient 537.25 429.8 IMA of Louisiana Commercial PPO 456.66 percent of total billed charges 295.49 1300 Reimbursement at 85% of billed charges ARTHROSCOPY OF JOINT 29999 CPT 360 RC outpatient 537.25 429.8 Aetna Commercial PPO 1300 fee schedule 295.49 1300 Case Rate GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 100 9833.63 80% of billed charges GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 100 9833.63 55% of Billed Charges GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 100 9833.63 Reimbursement at 85% of billed charges GRAFT REPAIR OF SPINE DEFECT 63710 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 100 fee schedule 100 9833.63 Case Rate "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges "NBLOCK INJ, ILIO-ING/HYPOGI" 64425 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges INJ FORAMEN EPIDURAL L/S 64483 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges "NBLOCK, STELLATE GANGLION" 64510 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate REVISE HAND/FOOT NERVE 64704 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges REVISE HAND/FOOT NERVE 64704 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges REVISE HAND/FOOT NERVE 64704 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges REVISE HAND/FOOT NERVE 64704 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges REVISE HAND/FOOT NERVE 64704 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges REVISE HAND/FOOT NERVE 64704 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC inpatient 3059.95 1529.98 BCBS Louisiana PPO 1529.98 percent of total billed charges 1529.98 2600.96 50% of Eligible Charges REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC outpatient 3059.95 2447.96 BCBS Louisiana PPO 2447.96 percent of total billed charges 1300 2600.96 80% of billed charges REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC outpatient 3059.95 2447.96 Cigna Commercial PPO 1682.97 percent of total billed charges 1300 2600.96 55% of Billed Charges REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC inpatient 3059.95 1529.98 IMA of Louisiana Commercial PPO 2600.96 percent of total billed charges 1529.98 2600.96 Inpatient Reimbursement at 85% of Billed Charges REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC outpatient 3059.95 2447.96 IMA of Louisiana Commercial PPO 2600.96 percent of total billed charges 1300 2600.96 Reimbursement at 85% of billed charges REVISE ULNAR NERVE AT ELBOW 64718 CPT 360 RC outpatient 3059.95 2447.96 Aetna Commercial PPO 1300 fee schedule 1300 2600.96 Case Rate REMOVE DIGIT NERVE LESION 64776 CPT 360 RC inpatient 3952.93 1976.47 BCBS Louisiana PPO 1976.47 percent of total billed charges 1976.47 3359.99 50% of Eligible Charges REMOVE DIGIT NERVE LESION 64776 CPT 360 RC outpatient 3952.93 3162.34 BCBS Louisiana PPO 3162.34 percent of total billed charges 1300 3359.99 80% of billed charges REMOVE DIGIT NERVE LESION 64776 CPT 360 RC outpatient 3952.93 3162.34 Cigna Commercial PPO 2174.11 percent of total billed charges 1300 3359.99 55% of Billed Charges REMOVE DIGIT NERVE LESION 64776 CPT 360 RC inpatient 3952.93 1976.47 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1976.47 3359.99 Inpatient Reimbursement at 85% of Billed Charges REMOVE DIGIT NERVE LESION 64776 CPT 360 RC outpatient 3952.93 3162.34 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1300 3359.99 Reimbursement at 85% of billed charges REMOVE DIGIT NERVE LESION 64776 CPT 360 RC outpatient 3952.93 3162.34 Aetna Commercial PPO 1300 fee schedule 1300 3359.99 Case Rate INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges INJECTION ANESTHETIC AGENT AXILLARY NERV 64417 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges LAMINECTOMY FACETECTOMY FORAMINOTOMY 63046 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC inpatient 2561.25 1280.63 BCBS Louisiana PPO 1280.63 percent of total billed charges 1280.63 2177.06 50% of Eligible Charges BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC outpatient 2561.25 2049 BCBS Louisiana PPO 2049 percent of total billed charges 1300 2177.06 80% of billed charges BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC outpatient 2561.25 2049 Cigna Commercial PPO 1408.69 percent of total billed charges 1300 2177.06 55% of Billed Charges BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC inpatient 2561.25 1280.63 IMA of Louisiana Commercial PPO 2177.06 percent of total billed charges 1280.63 2177.06 Inpatient Reimbursement at 85% of Billed Charges BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC outpatient 2561.25 2049 IMA of Louisiana Commercial PPO 2177.06 percent of total billed charges 1300 2177.06 Reimbursement at 85% of billed charges BONE MARROW ASPIRATION ONLY 38220 CPT 360 RC outpatient 2561.25 2049 Aetna Commercial PPO 1300 fee schedule 1300 2177.06 Case Rate KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC inpatient 6216.3 3108.15 BCBS Louisiana PPO 3108.15 percent of total billed charges 3108.15 5283.86 50% of Eligible Charges KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC outpatient 6216.3 4973.04 BCBS Louisiana PPO 4973.04 percent of total billed charges 1300 5283.86 80% of billed charges KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC outpatient 6216.3 4973.04 Cigna Commercial PPO 3418.97 percent of total billed charges 1300 5283.86 55% of Billed Charges KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC inpatient 6216.3 3108.15 IMA of Louisiana Commercial PPO 5283.86 percent of total billed charges 3108.15 5283.86 Inpatient Reimbursement at 85% of Billed Charges KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC outpatient 6216.3 4973.04 IMA of Louisiana Commercial PPO 5283.86 percent of total billed charges 1300 5283.86 Reimbursement at 85% of billed charges KNEE ARTHROSCOPY DRILLING FOR OSTEOCHOND 29886 CPT 360 RC outpatient 6216.3 4973.04 Aetna Commercial PPO 1300 fee schedule 1300 5283.86 Case Rate TREAT SPINAL CORD LESION 62281 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges TREAT SPINAL CORD LESION 62281 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges TREAT SPINAL CORD LESION 62281 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges TREAT SPINAL CORD LESION 62281 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges TREAT SPINAL CORD LESION 62281 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges TREAT SPINAL CORD LESION 62281 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges KNEE ARTHROSCOPY SYNOVECTOMY TWO OR MORE 29876 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges ELBOW ARTHROSCOPY WITH EXTENSIVE DEBRIDE 29838 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate BIOPSY OF NERVE 64795 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges BIOPSY OF NERVE 64795 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges BIOPSY OF NERVE 64795 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges BIOPSY OF NERVE 64795 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges BIOPSY OF NERVE 64795 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges BIOPSY OF NERVE 64795 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC inpatient 5621.13 2810.57 BCBS Louisiana PPO 2810.57 percent of total billed charges 2810.57 4777.96 50% of Eligible Charges SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC outpatient 5621.13 4496.9 BCBS Louisiana PPO 4496.9 percent of total billed charges 1300 4777.96 80% of billed charges SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC outpatient 5621.13 4496.9 Cigna Commercial PPO 3091.62 percent of total billed charges 1300 4777.96 55% of Billed Charges SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC inpatient 5621.13 2810.57 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 2810.57 4777.96 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC outpatient 5621.13 4496.9 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 1300 4777.96 Reimbursement at 85% of billed charges SHOULDER ARTHROSCOPY LYSIS AND RESECTION 29825 CPT 360 RC outpatient 5621.13 4496.9 Aetna Commercial PPO 1300 fee schedule 1300 4777.96 Case Rate CARDIAC SURGERY 33999 CPT 360 RC inpatient 1531.43 765.72 BCBS Louisiana PPO 765.72 percent of total billed charges 765.72 1301.72 50% of Eligible Charges CARDIAC SURGERY 33999 CPT 360 RC outpatient 1531.43 1225.14 BCBS Louisiana PPO 1225.14 percent of total billed charges 100 1301.72 80% of billed charges CARDIAC SURGERY 33999 CPT 360 RC outpatient 1531.43 1225.14 Cigna Commercial PPO 842.29 percent of total billed charges 100 1301.72 55% of Billed Charges CARDIAC SURGERY 33999 CPT 360 RC inpatient 1531.43 765.72 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 765.72 1301.72 Inpatient Reimbursement at 85% of Billed Charges CARDIAC SURGERY 33999 CPT 360 RC outpatient 1531.43 1225.14 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 100 1301.72 Reimbursement at 85% of billed charges CARDIAC SURGERY 33999 CPT 360 RC outpatient 1531.43 1225.14 Aetna Commercial PPO 100 fee schedule 100 1301.72 Case Rate INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges INJECTION ANESTHETIC AGENT SCIATIC NERVE 64445 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC inpatient 6480.83 3240.42 BCBS Louisiana PPO 3240.42 percent of total billed charges 3240.42 5508.71 50% of Eligible Charges KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC outpatient 6480.83 5184.66 BCBS Louisiana PPO 5184.66 percent of total billed charges 1300 5508.71 80% of billed charges KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC outpatient 6480.83 5184.66 Cigna Commercial PPO 3564.46 percent of total billed charges 1300 5508.71 55% of Billed Charges KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC inpatient 6480.83 3240.42 IMA of Louisiana Commercial PPO 5508.71 percent of total billed charges 3240.42 5508.71 Inpatient Reimbursement at 85% of Billed Charges KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC outpatient 6480.83 5184.66 IMA of Louisiana Commercial PPO 5508.71 percent of total billed charges 1300 5508.71 Reimbursement at 85% of billed charges KNEE ARTHROSCOPY INFECTION LAVAGE DRAIN 29871 CPT 360 RC outpatient 6480.83 5184.66 Aetna Commercial PPO 1300 fee schedule 1300 5508.71 Case Rate ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC inpatient 25307.3 12653.65 BCBS Louisiana PPO 12653.65 percent of total billed charges 12653.65 21511.21 50% of Eligible Charges ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC outpatient 25307.3 20245.84 BCBS Louisiana PPO 20245.84 percent of total billed charges 1300 21511.21 80% of billed charges ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC outpatient 25307.3 20245.84 Cigna Commercial PPO 13919.02 percent of total billed charges 1300 21511.21 55% of Billed Charges ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC inpatient 25307.3 12653.65 IMA of Louisiana Commercial PPO 21511.21 percent of total billed charges 12653.65 21511.21 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC outpatient 25307.3 20245.84 IMA of Louisiana Commercial PPO 21511.21 percent of total billed charges 1300 21511.21 Reimbursement at 85% of billed charges ARTHROSCOPY SUBTALAR JOINT WITH ARTHRODE 29907 CPT 360 RC outpatient 25307.3 20245.84 Aetna Commercial PPO 1300 fee schedule 1300 21511.21 Case Rate ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC inpatient 9390.75 4695.38 BCBS Louisiana PPO 4695.38 percent of total billed charges 4695.38 7982.14 50% of Eligible Charges ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC outpatient 9390.75 7512.6 BCBS Louisiana PPO 7512.6 percent of total billed charges 1300 7982.14 80% of billed charges ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC outpatient 9390.75 7512.6 Cigna Commercial PPO 5164.91 percent of total billed charges 1300 7982.14 55% of Billed Charges ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC inpatient 9390.75 4695.38 IMA of Louisiana Commercial PPO 7982.14 percent of total billed charges 4695.38 7982.14 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC outpatient 9390.75 7512.6 IMA of Louisiana Commercial PPO 7982.14 percent of total billed charges 1300 7982.14 Reimbursement at 85% of billed charges ARTHROSCOPY HIP W/FEMOROPLASTY 29914 CPT 360 RC outpatient 9390.75 7512.6 Aetna Commercial PPO 1300 fee schedule 1300 7982.14 Case Rate ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOO 29834 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges RPL IRRIGATION/REVJ LUBOS SHUNT 63744 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC inpatient 45 22.5 BCBS Louisiana PPO 22.5 percent of total billed charges 22.5 38.25 50% of Eligible Charges PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC outpatient 45 36 BCBS Louisiana PPO 36 percent of total billed charges 24.75 85 80% of billed charge PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC outpatient 45 36 Cigna Commercial PPO 85 other 24.75 85 63% of Billed Charges PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC inpatient 45 22.5 IMA of Louisiana Commercial PPO 38.25 percent of total billed charges 22.5 38.25 Inpatient Reimbursement at 85% of Billed Charges PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC outpatient 45 36 IMA of Louisiana Commercial PPO 38.25 percent of total billed charges 24.75 85 Reimbursement at 85% of billed charges PHYSICAL THERAPY RE-EVALUATION 97002 CPT 424 RC outpatient 45 36 Aetna Commercial PPO 24.75 percent of total billed charges 24.75 85 55 of billed Charges PT ULTRASOUND 97035 CPT 421 RC inpatient 33.95 16.98 BCBS Louisiana PPO 16.98 percent of total billed charges 16.98 28.86 50% of Eligible Charges PT ULTRASOUND 97035 CPT 421 RC outpatient 33.95 27.16 BCBS Louisiana PPO 27.16 percent of total billed charges 24.8 85 80% of billed charge PT ULTRASOUND 97035 CPT 421 RC outpatient 33.95 27.16 Cigna Commercial PPO 85 other 24.8 85 63% of Billed Charges PT ULTRASOUND 97035 CPT 421 RC inpatient 33.95 16.98 IMA of Louisiana Commercial PPO 28.86 percent of total billed charges 16.98 28.86 Inpatient Reimbursement at 85% of Billed Charges PT ULTRASOUND 97035 CPT 421 RC outpatient 33.95 27.16 IMA of Louisiana Commercial PPO 28.86 percent of total billed charges 24.8 85 Reimbursement at 85% of billed charges PT ULTRASOUND 97035 CPT 421 RC outpatient 33.95 27.16 Aetna Commercial PPO 24.8 fee schedule 24.8 85 200% Of Aetna Market Fee Schedule PT PHONOPHORESIS 97039 CPT 421 RC inpatient 45.26 22.63 BCBS Louisiana PPO 22.63 percent of total billed charges 22.63 38.47 50% of Eligible Charges PT PHONOPHORESIS 97039 CPT 421 RC outpatient 45.26 36.21 BCBS Louisiana PPO 36.21 percent of total billed charges 36.21 400 80% of billed charge PT PHONOPHORESIS 97039 CPT 421 RC outpatient 45.26 36.21 Cigna Commercial PPO 85 other 36.21 400 63% of Billed Charges PT PHONOPHORESIS 97039 CPT 421 RC inpatient 45.26 22.63 IMA of Louisiana Commercial PPO 38.47 percent of total billed charges 22.63 38.47 Inpatient Reimbursement at 85% of Billed Charges PT PHONOPHORESIS 97039 CPT 421 RC outpatient 45.26 36.21 IMA of Louisiana Commercial PPO 38.47 percent of total billed charges 36.21 400 Reimbursement at 85% of billed charges PT PHONOPHORESIS 97039 CPT 421 RC outpatient 45.26 36.21 Aetna Commercial PPO 400 fee schedule 36.21 400 200% Of Aetna Market Fee Schedule PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC inpatient 161.11 80.56 BCBS Louisiana PPO 80.56 percent of total billed charges 80.56 136.94 50% of Eligible Charges PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC outpatient 161.11 128.89 BCBS Louisiana PPO 128.89 percent of total billed charges 85 136.94 80% of billed charge PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC outpatient 161.11 128.89 Cigna Commercial PPO 85 other 85 136.94 63% of Billed Charges PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC inpatient 161.11 80.56 IMA of Louisiana Commercial PPO 136.94 percent of total billed charges 80.56 136.94 Inpatient Reimbursement at 85% of Billed Charges PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC outpatient 161.11 128.89 IMA of Louisiana Commercial PPO 136.94 percent of total billed charges 85 136.94 Reimbursement at 85% of billed charges PT WORK CONDITIONING EACH ADDITIONAL HR 97546 CPT 421 RC outpatient 161.11 128.89 Aetna Commercial PPO 101.08 fee schedule 85 136.94 200% Of Aetna Market Fee Schedule SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC inpatient 7751.23 3875.62 BCBS Louisiana PPO 3875.62 percent of total billed charges 3875.62 6588.55 50% of Eligible Charges SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC outpatient 7751.23 6200.98 BCBS Louisiana PPO 6200.98 percent of total billed charges 1300 6588.55 80% of billed charges SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC outpatient 7751.23 6200.98 Cigna Commercial PPO 4263.18 percent of total billed charges 1300 6588.55 55% of Billed Charges SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC inpatient 7751.23 3875.62 IMA of Louisiana Commercial PPO 6588.55 percent of total billed charges 3875.62 6588.55 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC outpatient 7751.23 6200.98 IMA of Louisiana Commercial PPO 6588.55 percent of total billed charges 1300 6588.55 Reimbursement at 85% of billed charges SUTURE 1 NERVE ULNAR MOTOR 64836 CPT 360 RC outpatient 7751.23 6200.98 Aetna Commercial PPO 1300 fee schedule 1300 6588.55 Case Rate LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges LAMIN W/ DECOMP SINGLE CERVICAL 63040 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 100 11913.64 6800 case rate LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges LAM BX/EXC ISPI NEO IDRL XMED LMBR 63282 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC inpatient 5832.3 2916.15 BCBS Louisiana PPO 2916.15 percent of total billed charges 2916.15 4957.46 50% of Eligible Charges EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC outpatient 5832.3 4665.84 BCBS Louisiana PPO 4665.84 percent of total billed charges 1300 4957.46 80% of billed charges EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC outpatient 5832.3 4665.84 Cigna Commercial PPO 3207.77 percent of total billed charges 1300 4957.46 55% of Billed Charges EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC inpatient 5832.3 2916.15 IMA of Louisiana Commercial PPO 4957.46 percent of total billed charges 2916.15 4957.46 Inpatient Reimbursement at 85% of Billed Charges EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC outpatient 5832.3 4665.84 IMA of Louisiana Commercial PPO 4957.46 percent of total billed charges 1300 4957.46 Reimbursement at 85% of billed charges EXPL LAPT EXPL CELIOTOMY +-BX SPX 49000 CPT 360 RC outpatient 5832.3 4665.84 Aetna Commercial PPO 1300 fee schedule 1300 4957.46 Case Rate ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC inpatient 10652.2 5326.1 BCBS Louisiana PPO 5326.1 percent of total billed charges 5326.1 9054.37 50% of Eligible Charges ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC outpatient 10652.2 8521.76 BCBS Louisiana PPO 8521.76 percent of total billed charges 1300 9054.37 80% of billed charges ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC outpatient 10652.2 8521.76 Cigna Commercial PPO 5858.71 percent of total billed charges 1300 9054.37 55% of Billed Charges ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC inpatient 10652.2 5326.1 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 5326.1 9054.37 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC outpatient 10652.2 8521.76 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 1300 9054.37 Reimbursement at 85% of billed charges ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOS 29866 CPT 360 RC outpatient 10652.2 8521.76 Aetna Commercial PPO 1300 fee schedule 1300 9054.37 Case Rate NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges NJX INTERLAMINAR CRV/THRC 62321 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate US EXAM PELVIC LIMITED 76857 CPT 360 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges US EXAM PELVIC LIMITED 76857 CPT 360 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges US EXAM PELVIC LIMITED 76857 CPT 360 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges US EXAM PELVIC LIMITED 76857 CPT 360 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges US EXAM PELVIC LIMITED 76857 CPT 360 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges US EXAM PELVIC LIMITED 76857 CPT 360 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT TOES 73660 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT TOES 73660 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT TOES 73660 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT TOES 73660 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT TOES 73660 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT TOES 73660 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC inpatient 145 72.5 BCBS Louisiana PPO 72.5 percent of total billed charges 72.5 123.25 50% of Eligible Charges "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC outpatient 145 116 BCBS Louisiana PPO 116 percent of total billed charges 79.75 123.25 80% of billed charge "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC outpatient 145 116 Cigna Commercial PPO 79.75 percent of total billed charges 79.75 123.25 55% of Billed Charges "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC inpatient 145 72.5 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 72.5 123.25 Inpatient Reimbursement at 85% of Billed Charges "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC outpatient 145 116 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 79.75 123.25 Reimbursement at 85% of billed charges "XRAY ABDOMEN, COMP. - PROFESSIONAL" 74020 CPT 972 RC outpatient 145 116 Aetna Commercial PPO 79.75 percent of total billed charges 79.75 123.25 55 of billed Charges CT OF KNEE W/O CONTRAST 73702 CPT 350 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT OF KNEE W/O CONTRAST 73702 CPT 350 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT OF KNEE W/O CONTRAST 73702 CPT 350 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT OF KNEE W/O CONTRAST 73702 CPT 350 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT OF KNEE W/O CONTRAST 73702 CPT 350 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT OF KNEE W/O CONTRAST 73702 CPT 350 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition RADEX SHO ARTHG RS&I 73040 CPT 320 RC inpatient 1140.93 570.47 BCBS Louisiana PPO 570.47 percent of total billed charges 570.47 969.79 50% of Eligible Charges RADEX SHO ARTHG RS&I 73040 CPT 320 RC outpatient 1140.93 798.65 BCBS Louisiana PPO 798.65 percent of total billed charges 627.51 969.79 70% of billed charges RADEX SHO ARTHG RS&I 73040 CPT 320 RC outpatient 1140.93 798.65 Cigna Commercial PPO 627.51 percent of total billed charges 627.51 969.79 55% of Billed Charges RADEX SHO ARTHG RS&I 73040 CPT 320 RC inpatient 1140.93 570.47 IMA of Louisiana Commercial PPO 969.79 percent of total billed charges 570.47 969.79 Inpatient Reimbursement at 85% of Billed Charges RADEX SHO ARTHG RS&I 73040 CPT 320 RC outpatient 1140.93 798.65 IMA of Louisiana Commercial PPO 969.79 percent of total billed charges 627.51 969.79 Reimbursement at 85% of billed charges RADEX SHO ARTHG RS&I 73040 CPT 320 RC outpatient 1140.93 798.65 Aetna Commercial PPO 700 case rate 627.51 969.79 700 Per Code Per DOS Paid In Addition CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT LEFT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT RIGHT LOWER EXT W/O AND W/ CONTRAST 73702 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC inpatient 101.96 50.98 BCBS Louisiana PPO 50.98 percent of total billed charges 50.98 86.67 50% of Eligible Charges PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC outpatient 101.96 81.57 BCBS Louisiana PPO 81.57 percent of total billed charges 61.9 86.67 80% of billed charge PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC outpatient 101.96 81.57 Cigna Commercial PPO 85 other 61.9 86.67 63% of Billed Charges PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC inpatient 101.96 50.98 IMA of Louisiana Commercial PPO 86.67 percent of total billed charges 50.98 86.67 Inpatient Reimbursement at 85% of Billed Charges PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC outpatient 101.96 81.57 IMA of Louisiana Commercial PPO 86.67 percent of total billed charges 61.9 86.67 Reimbursement at 85% of billed charges PT EXERCISES TO DEVELOP STRENGTH 97110 CPT 421 RC outpatient 101.96 81.57 Aetna Commercial PPO 61.9 fee schedule 61.9 86.67 200% Of Aetna Market Fee Schedule PT ORTHOTICS FITTING AND TRAINING 97760 CPT 421 RC outpatient Cigna Commercial PPO 85 other 85 85 63% of Billed Charges PT PT EVALUATION 97001 CPT 424 RC inpatient 612.5 306.25 BCBS Louisiana PPO 306.25 percent of total billed charges 306.25 520.63 50% of Eligible Charges PT PT EVALUATION 97001 CPT 424 RC outpatient 612.5 490 BCBS Louisiana PPO 490 percent of total billed charges 85 520.63 80% of billed charge PT PT EVALUATION 97001 CPT 424 RC outpatient 612.5 490 Cigna Commercial PPO 85 other 85 520.63 63% of Billed Charges PT PT EVALUATION 97001 CPT 424 RC inpatient 612.5 306.25 IMA of Louisiana Commercial PPO 520.63 percent of total billed charges 306.25 520.63 Inpatient Reimbursement at 85% of Billed Charges PT PT EVALUATION 97001 CPT 424 RC outpatient 612.5 490 IMA of Louisiana Commercial PPO 520.63 percent of total billed charges 85 520.63 Reimbursement at 85% of billed charges PT PT EVALUATION 97001 CPT 424 RC outpatient 612.5 490 Aetna Commercial PPO 336.88 percent of total billed charges 85 520.63 55 of billed Charges GROUNDING PAD RF - STRYKER 272 RC inpatient 634.94 317.47 BCBS Louisiana PPO 317.47 percent of total billed charges 317.47 539.7 50% of Eligible Charges GROUNDING PAD RF - STRYKER 272 RC outpatient 634.94 507.95 BCBS Louisiana PPO 507.95 percent of total billed charges 349.22 539.7 80% of billed charge GROUNDING PAD RF - STRYKER 272 RC outpatient 634.94 507.95 Cigna Commercial PPO 349.22 percent of total billed charges 349.22 539.7 55% of Billed Charges GROUNDING PAD RF - STRYKER 272 RC inpatient 634.94 317.47 IMA of Louisiana Commercial PPO 539.7 percent of total billed charges 317.47 539.7 Inpatient Reimbursement at 85% of Billed Charges GROUNDING PAD RF - STRYKER 272 RC outpatient 634.94 507.95 IMA of Louisiana Commercial PPO 539.7 percent of total billed charges 349.22 539.7 Reimbursement at 85% of billed charges GROUNDING PAD RF - STRYKER 272 RC outpatient 634.94 507.95 Aetna Commercial PPO 349.22 percent of total billed charges 349.22 539.7 55 of billed Charges EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC inpatient 454.78 227.39 BCBS Louisiana PPO 227.39 percent of total billed charges 227.39 386.56 50% of Eligible Charges EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC outpatient 454.78 363.82 BCBS Louisiana PPO 363.82 percent of total billed charges 250.13 386.56 80% of billed charge EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC outpatient 454.78 363.82 Cigna Commercial PPO 250.13 percent of total billed charges 250.13 386.56 55% of Billed Charges EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC inpatient 454.78 227.39 IMA of Louisiana Commercial PPO 386.56 percent of total billed charges 227.39 386.56 Inpatient Reimbursement at 85% of Billed Charges EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC outpatient 454.78 363.82 IMA of Louisiana Commercial PPO 386.56 percent of total billed charges 250.13 386.56 Reimbursement at 85% of billed charges EDM LUMBAR CATHETER FOR DUET DRAIN 272 RC outpatient 454.78 363.82 Aetna Commercial PPO 250.13 percent of total billed charges 250.13 386.56 55 of billed Charges DRESSING OPSITE 4X10 272 RC inpatient 39.56 19.78 BCBS Louisiana PPO 19.78 percent of total billed charges 19.78 33.63 50% of Eligible Charges DRESSING OPSITE 4X10 272 RC outpatient 39.56 31.65 BCBS Louisiana PPO 31.65 percent of total billed charges 21.76 33.63 80% of billed charge DRESSING OPSITE 4X10 272 RC outpatient 39.56 31.65 Cigna Commercial PPO 21.76 percent of total billed charges 21.76 33.63 55% of Billed Charges DRESSING OPSITE 4X10 272 RC inpatient 39.56 19.78 IMA of Louisiana Commercial PPO 33.63 percent of total billed charges 19.78 33.63 Inpatient Reimbursement at 85% of Billed Charges DRESSING OPSITE 4X10 272 RC outpatient 39.56 31.65 IMA of Louisiana Commercial PPO 33.63 percent of total billed charges 21.76 33.63 Reimbursement at 85% of billed charges DRESSING OPSITE 4X10 272 RC outpatient 39.56 31.65 Aetna Commercial PPO 21.76 percent of total billed charges 21.76 33.63 55 of billed Charges WALKER PEDIATRIC 270 RC inpatient 309.4 154.7 BCBS Louisiana PPO 154.7 percent of total billed charges 154.7 262.99 50% of Eligible Charges WALKER PEDIATRIC 270 RC outpatient 309.4 247.52 BCBS Louisiana PPO 247.52 percent of total billed charges 170.17 262.99 80% of billed charge WALKER PEDIATRIC 270 RC outpatient 309.4 247.52 Cigna Commercial PPO 170.17 percent of total billed charges 170.17 262.99 55% of Billed Charges WALKER PEDIATRIC 270 RC inpatient 309.4 154.7 IMA of Louisiana Commercial PPO 262.99 percent of total billed charges 154.7 262.99 Inpatient Reimbursement at 85% of Billed Charges WALKER PEDIATRIC 270 RC outpatient 309.4 247.52 IMA of Louisiana Commercial PPO 262.99 percent of total billed charges 170.17 262.99 Reimbursement at 85% of billed charges WALKER PEDIATRIC 270 RC outpatient 309.4 247.52 Aetna Commercial PPO 170.17 percent of total billed charges 170.17 262.99 55 of billed Charges OR SERVICES LEVEL 5 360 RC inpatient 4000 2000 BCBS Louisiana PPO 2000 percent of total billed charges 2000 3400 50% of Eligible Charges OR SERVICES LEVEL 5 360 RC outpatient 4000 3200 BCBS Louisiana PPO 3200 percent of total billed charges 2200 3400 80% of billed charge OR SERVICES LEVEL 5 360 RC outpatient 4000 3200 Cigna Commercial PPO 2200 percent of total billed charges 2200 3400 55% of Billed Charges OR SERVICES LEVEL 5 360 RC inpatient 4000 2000 IMA of Louisiana Commercial PPO 3400 percent of total billed charges 2000 3400 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 5 360 RC outpatient 4000 3200 IMA of Louisiana Commercial PPO 3400 percent of total billed charges 2200 3400 Reimbursement at 85% of billed charges OR SERVICES LEVEL 5 360 RC outpatient 4000 3200 Aetna Commercial PPO 2200 percent of total billed charges 2200 3400 55 of billed Charges OR SERVICES LEVEL 8 360 RC inpatient 15000 7500 BCBS Louisiana PPO 7500 percent of total billed charges 7500 12750 50% of Eligible Charges OR SERVICES LEVEL 8 360 RC outpatient 15000 12000 BCBS Louisiana PPO 12000 percent of total billed charges 8250 12750 80% of billed charge OR SERVICES LEVEL 8 360 RC outpatient 15000 12000 Cigna Commercial PPO 8250 percent of total billed charges 8250 12750 55% of Billed Charges OR SERVICES LEVEL 8 360 RC inpatient 15000 7500 IMA of Louisiana Commercial PPO 12750 percent of total billed charges 7500 12750 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 8 360 RC outpatient 15000 12000 IMA of Louisiana Commercial PPO 12750 percent of total billed charges 8250 12750 Reimbursement at 85% of billed charges OR SERVICES LEVEL 8 360 RC outpatient 15000 12000 Aetna Commercial PPO 8250 percent of total billed charges 8250 12750 55 of billed Charges OR SERVICES LEVEL 11 360 RC inpatient 35000 17500 BCBS Louisiana PPO 17500 percent of total billed charges 17500 29750 50% of Eligible Charges OR SERVICES LEVEL 11 360 RC outpatient 35000 28000 BCBS Louisiana PPO 28000 percent of total billed charges 19250 29750 80% of billed charge OR SERVICES LEVEL 11 360 RC outpatient 35000 28000 Cigna Commercial PPO 19250 percent of total billed charges 19250 29750 55% of Billed Charges OR SERVICES LEVEL 11 360 RC inpatient 35000 17500 IMA of Louisiana Commercial PPO 29750 percent of total billed charges 17500 29750 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 11 360 RC outpatient 35000 28000 IMA of Louisiana Commercial PPO 29750 percent of total billed charges 19250 29750 Reimbursement at 85% of billed charges OR SERVICES LEVEL 11 360 RC outpatient 35000 28000 Aetna Commercial PPO 19250 percent of total billed charges 19250 29750 55 of billed Charges OR SERVICES LEVEL 13 360 RC inpatient 50000 25000 BCBS Louisiana PPO 25000 percent of total billed charges 25000 42500 50% of Eligible Charges OR SERVICES LEVEL 13 360 RC outpatient 50000 40000 BCBS Louisiana PPO 40000 percent of total billed charges 27500 42500 80% of billed charge OR SERVICES LEVEL 13 360 RC outpatient 50000 40000 Cigna Commercial PPO 27500 percent of total billed charges 27500 42500 55% of Billed Charges OR SERVICES LEVEL 13 360 RC inpatient 50000 25000 IMA of Louisiana Commercial PPO 42500 percent of total billed charges 25000 42500 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 13 360 RC outpatient 50000 40000 IMA of Louisiana Commercial PPO 42500 percent of total billed charges 27500 42500 Reimbursement at 85% of billed charges OR SERVICES LEVEL 13 360 RC outpatient 50000 40000 Aetna Commercial PPO 27500 percent of total billed charges 27500 42500 55 of billed Charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges X-RAY EXAM LT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition PROC ROOM SERVICES 01 360 RC inpatient 620 310 BCBS Louisiana PPO 310 percent of total billed charges 310 527 50% of Eligible Charges PROC ROOM SERVICES 01 360 RC outpatient 620 496 BCBS Louisiana PPO 496 percent of total billed charges 341 527 80% of billed charge PROC ROOM SERVICES 01 360 RC outpatient 620 496 Cigna Commercial PPO 341 percent of total billed charges 341 527 55% of Billed Charges PROC ROOM SERVICES 01 360 RC inpatient 620 310 IMA of Louisiana Commercial PPO 527 percent of total billed charges 310 527 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 01 360 RC outpatient 620 496 IMA of Louisiana Commercial PPO 527 percent of total billed charges 341 527 Reimbursement at 85% of billed charges PROC ROOM SERVICES 01 360 RC outpatient 620 496 Aetna Commercial PPO 341 percent of total billed charges 341 527 55 of billed Charges PROC ROOM SERVICES 06 360 RC inpatient 1498 749 BCBS Louisiana PPO 749 percent of total billed charges 749 1273.3 50% of Eligible Charges PROC ROOM SERVICES 06 360 RC outpatient 1498 1198.4 BCBS Louisiana PPO 1198.4 percent of total billed charges 823.9 1273.3 80% of billed charge PROC ROOM SERVICES 06 360 RC outpatient 1498 1198.4 Cigna Commercial PPO 823.9 percent of total billed charges 823.9 1273.3 55% of Billed Charges PROC ROOM SERVICES 06 360 RC inpatient 1498 749 IMA of Louisiana Commercial PPO 1273.3 percent of total billed charges 749 1273.3 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 06 360 RC outpatient 1498 1198.4 IMA of Louisiana Commercial PPO 1273.3 percent of total billed charges 823.9 1273.3 Reimbursement at 85% of billed charges PROC ROOM SERVICES 06 360 RC outpatient 1498 1198.4 Aetna Commercial PPO 823.9 percent of total billed charges 823.9 1273.3 55 of billed Charges PROC ROOM SERVICES 07 360 RC inpatient 1733 866.5 BCBS Louisiana PPO 866.5 percent of total billed charges 866.5 1473.05 50% of Eligible Charges PROC ROOM SERVICES 07 360 RC outpatient 1733 1386.4 BCBS Louisiana PPO 1386.4 percent of total billed charges 953.15 1473.05 80% of billed charge PROC ROOM SERVICES 07 360 RC outpatient 1733 1386.4 Cigna Commercial PPO 953.15 percent of total billed charges 953.15 1473.05 55% of Billed Charges PROC ROOM SERVICES 07 360 RC inpatient 1733 866.5 IMA of Louisiana Commercial PPO 1473.05 percent of total billed charges 866.5 1473.05 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 07 360 RC outpatient 1733 1386.4 IMA of Louisiana Commercial PPO 1473.05 percent of total billed charges 953.15 1473.05 Reimbursement at 85% of billed charges PROC ROOM SERVICES 07 360 RC outpatient 1733 1386.4 Aetna Commercial PPO 953.15 percent of total billed charges 953.15 1473.05 55 of billed Charges PROC ROOM SERVICES 24 360 RC inpatient 4668 2334 BCBS Louisiana PPO 2334 percent of total billed charges 2334 3967.8 50% of Eligible Charges PROC ROOM SERVICES 24 360 RC outpatient 4668 3734.4 BCBS Louisiana PPO 3734.4 percent of total billed charges 2567.4 3967.8 80% of billed charge PROC ROOM SERVICES 24 360 RC outpatient 4668 3734.4 Cigna Commercial PPO 2567.4 percent of total billed charges 2567.4 3967.8 55% of Billed Charges PROC ROOM SERVICES 24 360 RC inpatient 4668 2334 IMA of Louisiana Commercial PPO 3967.8 percent of total billed charges 2334 3967.8 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 24 360 RC outpatient 4668 3734.4 IMA of Louisiana Commercial PPO 3967.8 percent of total billed charges 2567.4 3967.8 Reimbursement at 85% of billed charges PROC ROOM SERVICES 24 360 RC outpatient 4668 3734.4 Aetna Commercial PPO 2567.4 percent of total billed charges 2567.4 3967.8 55 of billed Charges PROC ROOM SERVICES 28 360 RC inpatient 8079 4039.5 BCBS Louisiana PPO 4039.5 percent of total billed charges 4039.5 6867.15 50% of Eligible Charges PROC ROOM SERVICES 28 360 RC outpatient 8079 6463.2 BCBS Louisiana PPO 6463.2 percent of total billed charges 4443.45 6867.15 80% of billed charge PROC ROOM SERVICES 28 360 RC outpatient 8079 6463.2 Cigna Commercial PPO 4443.45 percent of total billed charges 4443.45 6867.15 55% of Billed Charges PROC ROOM SERVICES 28 360 RC inpatient 8079 4039.5 IMA of Louisiana Commercial PPO 6867.15 percent of total billed charges 4039.5 6867.15 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 28 360 RC outpatient 8079 6463.2 IMA of Louisiana Commercial PPO 6867.15 percent of total billed charges 4443.45 6867.15 Reimbursement at 85% of billed charges PROC ROOM SERVICES 28 360 RC outpatient 8079 6463.2 Aetna Commercial PPO 4443.45 percent of total billed charges 4443.45 6867.15 55 of billed Charges PROC ROOM SERVICES 30 360 RC inpatient 30278 15139 BCBS Louisiana PPO 15139 percent of total billed charges 15139 25736.3 50% of Eligible Charges PROC ROOM SERVICES 30 360 RC outpatient 30278 24222.4 BCBS Louisiana PPO 24222.4 percent of total billed charges 16652.9 25736.3 80% of billed charge PROC ROOM SERVICES 30 360 RC outpatient 30278 24222.4 Cigna Commercial PPO 16652.9 percent of total billed charges 16652.9 25736.3 55% of Billed Charges PROC ROOM SERVICES 30 360 RC inpatient 30278 15139 IMA of Louisiana Commercial PPO 25736.3 percent of total billed charges 15139 25736.3 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 30 360 RC outpatient 30278 24222.4 IMA of Louisiana Commercial PPO 25736.3 percent of total billed charges 16652.9 25736.3 Reimbursement at 85% of billed charges PROC ROOM SERVICES 30 360 RC outpatient 30278 24222.4 Aetna Commercial PPO 16652.9 percent of total billed charges 16652.9 25736.3 55 of billed Charges REC ROOM 4.5 HR 710 RC inpatient 4725 2362.5 BCBS Louisiana PPO 2362.5 percent of total billed charges 2362.5 4016.25 50% of Eligible Charges REC ROOM 4.5 HR 710 RC outpatient 4725 3780 BCBS Louisiana PPO 3780 percent of total billed charges 2598.75 4016.25 80% of billed charge REC ROOM 4.5 HR 710 RC outpatient 4725 3780 Cigna Commercial PPO 2598.75 percent of total billed charges 2598.75 4016.25 55% of Billed Charges REC ROOM 4.5 HR 710 RC inpatient 4725 2362.5 IMA of Louisiana Commercial PPO 4016.25 percent of total billed charges 2362.5 4016.25 Inpatient Reimbursement at 85% of Billed Charges REC ROOM 4.5 HR 710 RC outpatient 4725 3780 IMA of Louisiana Commercial PPO 4016.25 percent of total billed charges 2598.75 4016.25 Reimbursement at 85% of billed charges REC ROOM 4.5 HR 710 RC outpatient 4725 3780 Aetna Commercial PPO 2598.75 percent of total billed charges 2598.75 4016.25 55 of billed Charges BMP 80048 CPT 300 RC inpatient 26.1 13.05 BCBS Louisiana PPO 13.05 percent of total billed charges 13.05 22.19 50% of Eligible Charges BMP 80048 CPT 300 RC outpatient 26.1 18.27 BCBS Louisiana PPO 18.27 percent of total billed charges 14.36 27.64 70% of billed charges BMP 80048 CPT 300 RC outpatient 26.1 18.27 Cigna Commercial PPO 14.36 percent of total billed charges 14.36 27.64 55% of Billed Charges BMP 80048 CPT 300 RC inpatient 26.1 13.05 IMA of Louisiana Commercial PPO 22.19 percent of total billed charges 13.05 22.19 Inpatient Reimbursement at 85% of Billed Charges BMP 80048 CPT 300 RC outpatient 26.1 18.27 IMA of Louisiana Commercial PPO 22.19 percent of total billed charges 14.36 27.64 Reimbursement at 85% of billed charges BMP 80048 CPT 300 RC outpatient 26.1 18.27 Aetna Commercial PPO 27.64 fee schedule 14.36 27.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate GRAM STAIN 87205 CPT 300 RC inpatient 13.18 6.59 BCBS Louisiana PPO 6.59 percent of total billed charges 6.59 11.2 50% of Eligible Charges GRAM STAIN 87205 CPT 300 RC outpatient 13.18 9.23 BCBS Louisiana PPO 9.23 percent of total billed charges 7.25 13.96 70% of billed charges GRAM STAIN 87205 CPT 300 RC outpatient 13.18 9.23 Cigna Commercial PPO 7.25 percent of total billed charges 7.25 13.96 55% of Billed Charges GRAM STAIN 87205 CPT 300 RC inpatient 13.18 6.59 IMA of Louisiana Commercial PPO 11.2 percent of total billed charges 6.59 11.2 Inpatient Reimbursement at 85% of Billed Charges GRAM STAIN 87205 CPT 300 RC outpatient 13.18 9.23 IMA of Louisiana Commercial PPO 11.2 percent of total billed charges 7.25 13.96 Reimbursement at 85% of billed charges GRAM STAIN 87205 CPT 300 RC outpatient 13.18 9.23 Aetna Commercial PPO 13.96 fee schedule 7.25 13.96 200% Of Aetna Market Fee Schedule Hospital Technical Rate COMPLETE METABOLIC PANEL 80053 CPT 300 RC inpatient 24.92 12.46 BCBS Louisiana PPO 12.46 percent of total billed charges 12.46 21.18 50% of Eligible Charges COMPLETE METABOLIC PANEL 80053 CPT 300 RC outpatient 24.92 17.44 BCBS Louisiana PPO 17.44 percent of total billed charges 13.71 34.54 70% of billed charges COMPLETE METABOLIC PANEL 80053 CPT 300 RC outpatient 24.92 17.44 Cigna Commercial PPO 13.71 percent of total billed charges 13.71 34.54 55% of Billed Charges COMPLETE METABOLIC PANEL 80053 CPT 300 RC inpatient 24.92 12.46 IMA of Louisiana Commercial PPO 21.18 percent of total billed charges 12.46 21.18 Inpatient Reimbursement at 85% of Billed Charges COMPLETE METABOLIC PANEL 80053 CPT 300 RC outpatient 24.92 17.44 IMA of Louisiana Commercial PPO 21.18 percent of total billed charges 13.71 34.54 Reimbursement at 85% of billed charges COMPLETE METABOLIC PANEL 80053 CPT 300 RC outpatient 24.92 17.44 Aetna Commercial PPO 34.54 fee schedule 13.71 34.54 200% Of Aetna Market Fee Schedule Hospital Technical Rate RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC inpatient 1118.68 559.34 BCBS Louisiana PPO 559.34 percent of total billed charges 559.34 950.88 50% of Eligible Charges RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC outpatient 1118.68 894.94 BCBS Louisiana PPO 894.94 percent of total billed charges 615.27 950.88 80% of billed charge RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC outpatient 1118.68 894.94 Cigna Commercial PPO 615.27 percent of total billed charges 615.27 950.88 55% of Billed Charges RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC inpatient 1118.68 559.34 IMA of Louisiana Commercial PPO 950.88 percent of total billed charges 559.34 950.88 Inpatient Reimbursement at 85% of Billed Charges RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC outpatient 1118.68 894.94 IMA of Louisiana Commercial PPO 950.88 percent of total billed charges 615.27 950.88 Reimbursement at 85% of billed charges RED BLOOD CELLS - LEUKOCYTES REDUCED P9016 HCPCS 381 RC outpatient 1118.68 894.94 Aetna Commercial PPO 615.27 percent of total billed charges 615.27 950.88 55 of billed Charges "PLATELETS, PHERESIS" P9034 HCPCS 384 RC inpatient 3016.92 1508.46 BCBS Louisiana PPO 1508.46 percent of total billed charges 1508.46 2564.38 50% of Eligible Charges "PLATELETS, PHERESIS" P9034 HCPCS 384 RC outpatient 3016.92 2413.54 BCBS Louisiana PPO 2413.54 percent of total billed charges 1659.31 2564.38 80% of billed charge "PLATELETS, PHERESIS" P9034 HCPCS 384 RC outpatient 3016.92 2413.54 Cigna Commercial PPO 1659.31 percent of total billed charges 1659.31 2564.38 55% of Billed Charges "PLATELETS, PHERESIS" P9034 HCPCS 384 RC inpatient 3016.92 1508.46 IMA of Louisiana Commercial PPO 2564.38 percent of total billed charges 1508.46 2564.38 Inpatient Reimbursement at 85% of Billed Charges "PLATELETS, PHERESIS" P9034 HCPCS 384 RC outpatient 3016.92 2413.54 IMA of Louisiana Commercial PPO 2564.38 percent of total billed charges 1659.31 2564.38 Reimbursement at 85% of billed charges "PLATELETS, PHERESIS" P9034 HCPCS 384 RC outpatient 3016.92 2413.54 Aetna Commercial PPO 1659.31 percent of total billed charges 1659.31 2564.38 55 of billed Charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC inpatient 269.6 134.8 BCBS Louisiana PPO 134.8 percent of total billed charges 134.8 229.16 50% of Eligible Charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC outpatient 269.6 188.72 BCBS Louisiana PPO 188.72 percent of total billed charges 41.16 229.16 70% of billed charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC outpatient 269.6 188.72 Cigna Commercial PPO 148.28 percent of total billed charges 41.16 229.16 55% of Billed Charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC inpatient 269.6 134.8 IMA of Louisiana Commercial PPO 229.16 percent of total billed charges 134.8 229.16 Inpatient Reimbursement at 85% of Billed Charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC outpatient 269.6 188.72 IMA of Louisiana Commercial PPO 229.16 percent of total billed charges 41.16 229.16 Reimbursement at 85% of billed charges FRESH FROZEN PLASMA - 180 ML 86927 CPT 300 RC outpatient 269.6 188.72 Aetna Commercial PPO 41.16 fee schedule 41.16 229.16 200% Of Aetna Market Fee Schedule Hospital Technical Rate T4 FREE 84439 CPT 300 RC inpatient 27.83 13.92 BCBS Louisiana PPO 13.92 percent of total billed charges 13.92 23.66 50% of Eligible Charges T4 FREE 84439 CPT 300 RC outpatient 27.83 19.48 BCBS Louisiana PPO 19.48 percent of total billed charges 15.31 29.48 70% of billed charges T4 FREE 84439 CPT 300 RC outpatient 27.83 19.48 Cigna Commercial PPO 15.31 percent of total billed charges 15.31 29.48 55% of Billed Charges T4 FREE 84439 CPT 300 RC inpatient 27.83 13.92 IMA of Louisiana Commercial PPO 23.66 percent of total billed charges 13.92 23.66 Inpatient Reimbursement at 85% of Billed Charges T4 FREE 84439 CPT 300 RC outpatient 27.83 19.48 IMA of Louisiana Commercial PPO 23.66 percent of total billed charges 15.31 29.48 Reimbursement at 85% of billed charges T4 FREE 84439 CPT 300 RC outpatient 27.83 19.48 Aetna Commercial PPO 29.48 fee schedule 15.31 29.48 200% Of Aetna Market Fee Schedule Hospital Technical Rate AB ID STD COM PANEL 86870 CPT 305 RC inpatient 538.58 269.29 BCBS Louisiana PPO 269.29 percent of total billed charges 269.29 457.79 50% of Eligible Charges AB ID STD COM PANEL 86870 CPT 305 RC outpatient 538.58 377.01 BCBS Louisiana PPO 377.01 percent of total billed charges 89.18 457.79 70% of billed charges AB ID STD COM PANEL 86870 CPT 305 RC outpatient 538.58 377.01 Cigna Commercial PPO 296.22 percent of total billed charges 89.18 457.79 55% of Billed Charges AB ID STD COM PANEL 86870 CPT 305 RC inpatient 538.58 269.29 IMA of Louisiana Commercial PPO 457.79 percent of total billed charges 269.29 457.79 Inpatient Reimbursement at 85% of Billed Charges AB ID STD COM PANEL 86870 CPT 305 RC outpatient 538.58 377.01 IMA of Louisiana Commercial PPO 457.79 percent of total billed charges 89.18 457.79 Reimbursement at 85% of billed charges AB ID STD COM PANEL 86870 CPT 305 RC outpatient 538.58 377.01 Aetna Commercial PPO 89.18 fee schedule 89.18 457.79 200% Of Aetna Market Fee Schedule Hospital Technical Rate VANCOMYCIN TROUGH 80202 CPT 300 RC inpatient 41.8 20.9 BCBS Louisiana PPO 20.9 percent of total billed charges 20.9 35.53 50% of Eligible Charges VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 BCBS Louisiana PPO 29.26 percent of total billed charges 22.99 44.3 70% of billed charges VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 Cigna Commercial PPO 22.99 percent of total billed charges 22.99 44.3 55% of Billed Charges VANCOMYCIN TROUGH 80202 CPT 300 RC inpatient 41.8 20.9 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 20.9 35.53 Inpatient Reimbursement at 85% of Billed Charges VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 22.99 44.3 Reimbursement at 85% of billed charges VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 Aetna Commercial PPO 44.3 fee schedule 22.99 44.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate VITAMIN B12 82607 CPT 301 RC inpatient 46.53 23.27 BCBS Louisiana PPO 23.27 percent of total billed charges 23.27 39.55 50% of Eligible Charges VITAMIN B12 82607 CPT 301 RC outpatient 46.53 32.57 BCBS Louisiana PPO 32.57 percent of total billed charges 25.59 49.3 70% of billed charges VITAMIN B12 82607 CPT 301 RC outpatient 46.53 32.57 Cigna Commercial PPO 25.59 percent of total billed charges 25.59 49.3 55% of Billed Charges VITAMIN B12 82607 CPT 301 RC inpatient 46.53 23.27 IMA of Louisiana Commercial PPO 39.55 percent of total billed charges 23.27 39.55 Inpatient Reimbursement at 85% of Billed Charges VITAMIN B12 82607 CPT 301 RC outpatient 46.53 32.57 IMA of Louisiana Commercial PPO 39.55 percent of total billed charges 25.59 49.3 Reimbursement at 85% of billed charges VITAMIN B12 82607 CPT 301 RC outpatient 46.53 32.57 Aetna Commercial PPO 49.3 fee schedule 25.59 49.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC inpatient 109.08 54.54 BCBS Louisiana PPO 54.54 percent of total billed charges 54.54 92.72 50% of Eligible Charges "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC outpatient 109.08 76.36 BCBS Louisiana PPO 76.36 percent of total billed charges 59.99 96.8 70% of billed charges "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC outpatient 109.08 76.36 Cigna Commercial PPO 59.99 percent of total billed charges 59.99 96.8 55% of Billed Charges "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC inpatient 109.08 54.54 IMA of Louisiana Commercial PPO 92.72 percent of total billed charges 54.54 92.72 Inpatient Reimbursement at 85% of Billed Charges "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC outpatient 109.08 76.36 IMA of Louisiana Commercial PPO 92.72 percent of total billed charges 59.99 96.8 Reimbursement at 85% of billed charges "VITAMIN D, 25-HYDROXY" 82306 CPT 300 RC outpatient 109.08 76.36 Aetna Commercial PPO 96.8 fee schedule 59.99 96.8 200% Of Aetna Market Fee Schedule Hospital Technical Rate CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC inpatient 24.93 12.47 BCBS Louisiana PPO 12.47 percent of total billed charges 12.47 21.19 50% of Eligible Charges CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC outpatient 24.93 17.45 BCBS Louisiana PPO 17.45 percent of total billed charges 13.71 26.4 70% of billed charges CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC outpatient 24.93 17.45 Cigna Commercial PPO 13.71 percent of total billed charges 13.71 26.4 55% of Billed Charges CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC inpatient 24.93 12.47 IMA of Louisiana Commercial PPO 21.19 percent of total billed charges 12.47 21.19 Inpatient Reimbursement at 85% of Billed Charges CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC outpatient 24.93 17.45 IMA of Louisiana Commercial PPO 21.19 percent of total billed charges 13.71 26.4 Reimbursement at 85% of billed charges CULTURE - AEROBIC ISOLATE 87077 CPT 300 RC outpatient 24.93 17.45 Aetna Commercial PPO 26.4 fee schedule 13.71 26.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_SEDIMENTATION RATE 85652 CPT 300 RC inpatient 11.48 5.74 BCBS Louisiana PPO 5.74 percent of total billed charges 5.74 9.76 50% of Eligible Charges prad_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 BCBS Louisiana PPO 8.04 percent of total billed charges 6.31 9.76 70% of billed charges prad_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 Cigna Commercial PPO 6.31 percent of total billed charges 6.31 9.76 55% of Billed Charges prad_SEDIMENTATION RATE 85652 CPT 300 RC inpatient 11.48 5.74 IMA of Louisiana Commercial PPO 9.76 percent of total billed charges 5.74 9.76 Inpatient Reimbursement at 85% of Billed Charges prad_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 IMA of Louisiana Commercial PPO 9.76 percent of total billed charges 6.31 9.76 Reimbursement at 85% of billed charges prad_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 Aetna Commercial PPO 8.84 fee schedule 6.31 9.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_H&H 85018 CPT 300 RC inpatient 7.33 3.67 BCBS Louisiana PPO 3.67 percent of total billed charges 3.67 6.23 50% of Eligible Charges inpt3_H&H 85018 CPT 300 RC outpatient 7.33 5.13 BCBS Louisiana PPO 5.13 percent of total billed charges 4.03 7.76 70% of billed charges inpt3_H&H 85018 CPT 300 RC outpatient 7.33 5.13 Cigna Commercial PPO 4.03 percent of total billed charges 4.03 7.76 55% of Billed Charges inpt3_H&H 85018 CPT 300 RC inpatient 7.33 3.67 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 3.67 6.23 Inpatient Reimbursement at 85% of Billed Charges inpt3_H&H 85018 CPT 300 RC outpatient 7.33 5.13 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 4.03 7.76 Reimbursement at 85% of billed charges inpt3_H&H 85018 CPT 300 RC outpatient 7.33 5.13 Aetna Commercial PPO 7.76 fee schedule 4.03 7.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_PTT 85730 CPT 300 RC inpatient 18.55 9.28 BCBS Louisiana PPO 9.28 percent of total billed charges 9.28 15.77 50% of Eligible Charges inpt3_PTT 85730 CPT 300 RC outpatient 18.55 12.99 BCBS Louisiana PPO 12.99 percent of total billed charges 10.2 19.64 70% of billed charges inpt3_PTT 85730 CPT 300 RC outpatient 18.55 12.99 Cigna Commercial PPO 10.2 percent of total billed charges 10.2 19.64 55% of Billed Charges inpt3_PTT 85730 CPT 300 RC inpatient 18.55 9.28 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 9.28 15.77 Inpatient Reimbursement at 85% of Billed Charges inpt3_PTT 85730 CPT 300 RC outpatient 18.55 12.99 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 10.2 19.64 Reimbursement at 85% of billed charges inpt3_PTT 85730 CPT 300 RC outpatient 18.55 12.99 Aetna Commercial PPO 19.64 fee schedule 10.2 19.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_RENAL FUNC PANEL 80069 CPT 300 RC inpatient 26.8 13.4 BCBS Louisiana PPO 13.4 percent of total billed charges 13.4 22.78 50% of Eligible Charges inpt3_RENAL FUNC PANEL 80069 CPT 300 RC outpatient 26.8 18.76 BCBS Louisiana PPO 18.76 percent of total billed charges 14.74 28.4 70% of billed charges inpt3_RENAL FUNC PANEL 80069 CPT 300 RC outpatient 26.8 18.76 Cigna Commercial PPO 14.74 percent of total billed charges 14.74 28.4 55% of Billed Charges inpt3_RENAL FUNC PANEL 80069 CPT 300 RC inpatient 26.8 13.4 IMA of Louisiana Commercial PPO 22.78 percent of total billed charges 13.4 22.78 Inpatient Reimbursement at 85% of Billed Charges inpt3_RENAL FUNC PANEL 80069 CPT 300 RC outpatient 26.8 18.76 IMA of Louisiana Commercial PPO 22.78 percent of total billed charges 14.74 28.4 Reimbursement at 85% of billed charges inpt3_RENAL FUNC PANEL 80069 CPT 300 RC outpatient 26.8 18.76 Aetna Commercial PPO 28.4 fee schedule 14.74 28.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_CKMB 82553 CPT 301 RC inpatient 35.65 17.83 BCBS Louisiana PPO 17.83 percent of total billed charges 17.83 30.3 50% of Eligible Charges inpt3_CKMB 82553 CPT 301 RC outpatient 35.65 24.96 BCBS Louisiana PPO 24.96 percent of total billed charges 19.61 37.76 70% of billed charges inpt3_CKMB 82553 CPT 301 RC outpatient 35.65 24.96 Cigna Commercial PPO 19.61 percent of total billed charges 19.61 37.76 55% of Billed Charges inpt3_CKMB 82553 CPT 301 RC inpatient 35.65 17.83 IMA of Louisiana Commercial PPO 30.3 percent of total billed charges 17.83 30.3 Inpatient Reimbursement at 85% of Billed Charges inpt3_CKMB 82553 CPT 301 RC outpatient 35.65 24.96 IMA of Louisiana Commercial PPO 30.3 percent of total billed charges 19.61 37.76 Reimbursement at 85% of billed charges inpt3_CKMB 82553 CPT 301 RC outpatient 35.65 24.96 Aetna Commercial PPO 37.76 fee schedule 19.61 37.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC inpatient 6.93 3.47 BCBS Louisiana PPO 3.47 percent of total billed charges 3.47 5.89 50% of Eligible Charges inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC outpatient 6.93 4.85 BCBS Louisiana PPO 4.85 percent of total billed charges 3.81 7.34 70% of billed charges inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC outpatient 6.93 4.85 Cigna Commercial PPO 3.81 percent of total billed charges 3.81 7.34 55% of Billed Charges inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC inpatient 6.93 3.47 IMA of Louisiana Commercial PPO 5.89 percent of total billed charges 3.47 5.89 Inpatient Reimbursement at 85% of Billed Charges inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC outpatient 6.93 4.85 IMA of Louisiana Commercial PPO 5.89 percent of total billed charges 3.81 7.34 Reimbursement at 85% of billed charges inpt3_URINALYSIS w/ REFLEX TO CX PRN 81003 CPT 300 RC outpatient 6.93 4.85 Aetna Commercial PPO 7.34 fee schedule 3.81 7.34 200% Of Aetna Market Fee Schedule Hospital Technical Rate AMYLASE 82150 CPT 300 RC inpatient 20 10 BCBS Louisiana PPO 10 percent of total billed charges 10 17 50% of Eligible Charges AMYLASE 82150 CPT 300 RC outpatient 20 14 BCBS Louisiana PPO 14 percent of total billed charges 11 21.2 70% of billed charges AMYLASE 82150 CPT 300 RC outpatient 20 14 Cigna Commercial PPO 11 percent of total billed charges 11 21.2 55% of Billed Charges AMYLASE 82150 CPT 300 RC inpatient 20 10 IMA of Louisiana Commercial PPO 17 percent of total billed charges 10 17 Inpatient Reimbursement at 85% of Billed Charges AMYLASE 82150 CPT 300 RC outpatient 20 14 IMA of Louisiana Commercial PPO 17 percent of total billed charges 11 21.2 Reimbursement at 85% of billed charges AMYLASE 82150 CPT 300 RC outpatient 20 14 Aetna Commercial PPO 21.2 fee schedule 11 21.2 200% Of Aetna Market Fee Schedule Hospital Technical Rate STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC inpatient 440 220 BCBS Louisiana PPO 220 percent of total billed charges 220 374 50% of Eligible Charges STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC outpatient 440 352 BCBS Louisiana PPO 352 percent of total billed charges 242 374 80% of billed charge STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC outpatient 440 352 Cigna Commercial PPO 242 percent of total billed charges 242 374 55% of Billed Charges STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC inpatient 440 220 IMA of Louisiana Commercial PPO 374 percent of total billed charges 220 374 Inpatient Reimbursement at 85% of Billed Charges STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC outpatient 440 352 IMA of Louisiana Commercial PPO 374 percent of total billed charges 242 374 Reimbursement at 85% of billed charges STORAGE FEE - LR BLOOD P9016 HCPCS 390 RC outpatient 440 352 Aetna Commercial PPO 242 percent of total billed charges 242 374 55 of billed Charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC inpatient 22.08 11.04 BCBS Louisiana PPO 11.04 percent of total billed charges 11.04 18.77 50% of Eligible Charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC outpatient 22.08 15.46 BCBS Louisiana PPO 15.46 percent of total billed charges 12.14 23.4 70% of billed charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC outpatient 22.08 15.46 Cigna Commercial PPO 12.14 percent of total billed charges 12.14 23.4 55% of Billed Charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC inpatient 22.08 11.04 IMA of Louisiana Commercial PPO 18.77 percent of total billed charges 11.04 18.77 Inpatient Reimbursement at 85% of Billed Charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC outpatient 22.08 15.46 IMA of Louisiana Commercial PPO 18.77 percent of total billed charges 12.14 23.4 Reimbursement at 85% of billed charges CRYSTAL ANALYSIS CHARGE - DPGSURG 89060 CPT 310 RC outpatient 22.08 15.46 Aetna Commercial PPO 23.4 fee schedule 12.14 23.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate NICOTINE SERUM LEVEL G0480 HCPCS 300 RC inpatient 286.08 143.04 BCBS Louisiana PPO 143.04 percent of total billed charges 143.04 243.17 50% of Eligible Charges NICOTINE SERUM LEVEL G0480 HCPCS 300 RC outpatient 286.08 228.86 BCBS Louisiana PPO 228.86 percent of total billed charges 157.34 243.17 80% of billed charge NICOTINE SERUM LEVEL G0480 HCPCS 300 RC outpatient 286.08 228.86 Cigna Commercial PPO 157.34 percent of total billed charges 157.34 243.17 55% of Billed Charges NICOTINE SERUM LEVEL G0480 HCPCS 300 RC inpatient 286.08 143.04 IMA of Louisiana Commercial PPO 243.17 percent of total billed charges 143.04 243.17 Inpatient Reimbursement at 85% of Billed Charges NICOTINE SERUM LEVEL G0480 HCPCS 300 RC outpatient 286.08 228.86 IMA of Louisiana Commercial PPO 243.17 percent of total billed charges 157.34 243.17 Reimbursement at 85% of billed charges NICOTINE SERUM LEVEL G0480 HCPCS 300 RC outpatient 286.08 228.86 Aetna Commercial PPO 157.34 percent of total billed charges 157.34 243.17 55 of billed Charges PSA SCREENING 84153 CPT 300 RC inpatient 56.78 28.39 BCBS Louisiana PPO 28.39 percent of total billed charges 28.39 48.26 50% of Eligible Charges PSA SCREENING 84153 CPT 300 RC outpatient 56.78 39.75 BCBS Louisiana PPO 39.75 percent of total billed charges 31.23 60.14 70% of billed charges PSA SCREENING 84153 CPT 300 RC outpatient 56.78 39.75 Cigna Commercial PPO 31.23 percent of total billed charges 31.23 60.14 55% of Billed Charges PSA SCREENING 84153 CPT 300 RC inpatient 56.78 28.39 IMA of Louisiana Commercial PPO 48.26 percent of total billed charges 28.39 48.26 Inpatient Reimbursement at 85% of Billed Charges PSA SCREENING 84153 CPT 300 RC outpatient 56.78 39.75 IMA of Louisiana Commercial PPO 48.26 percent of total billed charges 31.23 60.14 Reimbursement at 85% of billed charges PSA SCREENING 84153 CPT 300 RC outpatient 56.78 39.75 Aetna Commercial PPO 60.14 fee schedule 31.23 60.14 200% Of Aetna Market Fee Schedule Hospital Technical Rate URINE NICOTINE TEST G0480 HCPCS 300 RC inpatient 286.08 143.04 BCBS Louisiana PPO 143.04 percent of total billed charges 143.04 243.17 50% of Eligible Charges URINE NICOTINE TEST G0480 HCPCS 300 RC outpatient 286.08 228.86 BCBS Louisiana PPO 228.86 percent of total billed charges 157.34 243.17 80% of billed charge URINE NICOTINE TEST G0480 HCPCS 300 RC outpatient 286.08 228.86 Cigna Commercial PPO 157.34 percent of total billed charges 157.34 243.17 55% of Billed Charges URINE NICOTINE TEST G0480 HCPCS 300 RC inpatient 286.08 143.04 IMA of Louisiana Commercial PPO 243.17 percent of total billed charges 143.04 243.17 Inpatient Reimbursement at 85% of Billed Charges URINE NICOTINE TEST G0480 HCPCS 300 RC outpatient 286.08 228.86 IMA of Louisiana Commercial PPO 243.17 percent of total billed charges 157.34 243.17 Reimbursement at 85% of billed charges URINE NICOTINE TEST G0480 HCPCS 300 RC outpatient 286.08 228.86 Aetna Commercial PPO 157.34 percent of total billed charges 157.34 243.17 55 of billed Charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC inpatient 77.84 38.92 BCBS Louisiana PPO 38.92 percent of total billed charges 38.92 66.16 50% of Eligible Charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC outpatient 77.84 54.49 BCBS Louisiana PPO 54.49 percent of total billed charges 9.76 66.16 70% of billed charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC outpatient 77.84 54.49 Cigna Commercial PPO 42.81 percent of total billed charges 9.76 66.16 55% of Billed Charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC inpatient 77.84 38.92 IMA of Louisiana Commercial PPO 66.16 percent of total billed charges 38.92 66.16 Inpatient Reimbursement at 85% of Billed Charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC outpatient 77.84 54.49 IMA of Louisiana Commercial PPO 66.16 percent of total billed charges 9.76 66.16 Reimbursement at 85% of billed charges BLOOD TYPING - LIFESHARE 86901 CPT 300 RC outpatient 77.84 54.49 Aetna Commercial PPO 9.76 fee schedule 9.76 66.16 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT ELBOW 3 VIEWS 73080 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT SHOULDER 2 VIEWS 73030 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT inpatient 205 102.5 BCBS Louisiana PPO 102.5 percent of total billed charges 102.5 174.25 50% of Eligible Charges XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT outpatient 205 143.5 BCBS Louisiana PPO 143.5 percent of total billed charges 112.75 700 70% of billed charges XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT outpatient 205 143.5 Cigna Commercial PPO 112.75 percent of total billed charges 112.75 700 55% of Billed Charges XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT inpatient 205 102.5 IMA of Louisiana Commercial PPO 174.25 percent of total billed charges 102.5 174.25 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT outpatient 205 143.5 IMA of Louisiana Commercial PPO 174.25 percent of total billed charges 112.75 700 Reimbursement at 85% of billed charges XRAY DX LT HIP 1 VIEW 73501 CPT 320 RC LT outpatient 205 143.5 Aetna Commercial PPO 700 case rate 112.75 700 700 Per Code Per DOS Paid In Addition XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX AP/LAT LUMBAR SPINE - 2 VIEWS 72100 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC inpatient 5923.8 2961.9 BCBS Louisiana PPO 2961.9 percent of total billed charges 2961.9 5035.23 50% of Eligible Charges C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 5923.8 4739.04 BCBS Louisiana PPO 4739.04 percent of total billed charges 1300 5035.23 80% of billed charges C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 5923.8 4739.04 Cigna Commercial PPO 3258.09 percent of total billed charges 1300 5035.23 55% of Billed Charges C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC inpatient 5923.8 2961.9 IMA of Louisiana Commercial PPO 5035.23 percent of total billed charges 2961.9 5035.23 Inpatient Reimbursement at 85% of Billed Charges C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 5923.8 4739.04 IMA of Louisiana Commercial PPO 5035.23 percent of total billed charges 1300 5035.23 Reimbursement at 85% of billed charges C-ARM 5.01-10 MINUTES INTRADISCAL 22526 CPT 320 RC outpatient 5923.8 4739.04 Aetna Commercial PPO 1300 fee schedule 1300 5035.23 Case Rate C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC outpatient 4026.25 2818.38 BCBS Louisiana PPO 2818.38 percent of total billed charges 700 3422.31 70% of billed charges C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC outpatient 4026.25 2818.38 Cigna Commercial PPO 2214.44 percent of total billed charges 700 3422.31 55% of Billed Charges C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC outpatient 4026.25 2818.38 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 700 3422.31 Reimbursement at 85% of billed charges C-ARM DISCOGRAM 1ST LEVEL 72295 CPT 320 RC outpatient 4026.25 2818.38 Aetna Commercial PPO 700 case rate 700 3422.31 700 Per Code Per DOS Paid In Addition CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 347.52 700 70% of billed charges CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC outpatient 631.85 442.3 Cigna Commercial PPO 347.52 percent of total billed charges 347.52 700 55% of Billed Charges CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 347.52 700 Reimbursement at 85% of billed charges CT NECK SPINE W/O AND WITH DYE 72127 CPT 320 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 347.52 700 700 Per Code Per DOS Paid In Addition CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges CT OF BRAIN W/O CONTRAST 70450 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC inpatient 748.86 374.43 BCBS Louisiana PPO 374.43 percent of total billed charges 374.43 636.53 50% of Eligible Charges CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC outpatient 748.86 524.2 BCBS Louisiana PPO 524.2 percent of total billed charges 411.87 700 70% of billed charges CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC outpatient 748.86 524.2 Cigna Commercial PPO 411.87 percent of total billed charges 411.87 700 55% of Billed Charges CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC inpatient 748.86 374.43 IMA of Louisiana Commercial PPO 636.53 percent of total billed charges 374.43 636.53 Inpatient Reimbursement at 85% of Billed Charges CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC outpatient 748.86 524.2 IMA of Louisiana Commercial PPO 636.53 percent of total billed charges 411.87 700 Reimbursement at 85% of billed charges CT THORACIC SPINE WITHOUT DYE 72128 CPT 320 RC outpatient 748.86 524.2 Aetna Commercial PPO 700 case rate 411.87 700 700 Per Code Per DOS Paid In Addition X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges X-RAY SCOLI EVALUATION 2-3 VIEW 72082 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 200.31 700 70% of billed charges CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 Cigna Commercial PPO 700 other 200.31 700 $700 Per Visit CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 200.31 700 Reimbursement at 85% of billed charges CT RIGHT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 200.31 700 700 Per Code Per DOS Paid In Addition OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC inpatient 40 ME 4.07 2.04 BCBS Louisiana PPO 2.04 percent of total billed charges 2.04 3.46 50% of Eligible Charges OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC outpatient 40 ME 4.07 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 2.24 3.46 80% of billed charge OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC outpatient 40 ME 4.07 3.26 Cigna Commercial PPO 2.24 percent of total billed charges 2.24 3.46 55% of Billed Charges OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC inpatient 40 ME 4.07 2.04 IMA of Louisiana Commercial PPO 3.46 percent of total billed charges 2.04 3.46 Inpatient Reimbursement at 85% of Billed Charges OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC outpatient 40 ME 4.07 3.26 IMA of Louisiana Commercial PPO 3.46 percent of total billed charges 2.24 3.46 Reimbursement at 85% of billed charges OMEPRAZOLE 40MG CAP NON-FORMULA 250 RC 5026865711 NDC outpatient 40 ME 4.07 3.26 Aetna Commercial PPO 2.24 percent of total billed charges 2.24 3.46 55 of billed Charges CIALIS 5MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0002446230 NDC inpatient 5 ME 6.32 3.16 BCBS Louisiana PPO 3.16 percent of total billed charges 3.16 5.37 50% of Eligible Charges CIALIS 5MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0002446230 NDC outpatient 5 ME 6.32 5.06 BCBS Louisiana PPO 5.06 percent of total billed charges 3.48 5.37 80% of billed charge CIALIS 5MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0002446230 NDC outpatient 5 ME 6.32 5.06 Cigna Commercial PPO 3.48 percent of total billed charges 3.48 5.37 55% of Billed Charges CIALIS 5MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0002446230 NDC inpatient 5 ME 6.32 3.16 IMA of Louisiana Commercial PPO 5.37 percent of total billed charges 3.16 5.37 Inpatient Reimbursement at 85% of Billed Charges CIALIS 5MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0002446230 NDC outpatient 5 ME 6.32 5.06 IMA of Louisiana Commercial PPO 5.37 percent of total billed charges 3.48 5.37 Reimbursement at 85% of billed charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC inpatient 1 EA 1.02 0.51 BCBS Louisiana PPO 0.51 percent of total billed charges 0.51 0.87 50% of Eligible Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 1 EA 1.02 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.56 0.87 80% of billed charge SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 1 EA 1.02 0.82 Cigna Commercial PPO 0.56 percent of total billed charges 0.56 0.87 55% of Billed Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC inpatient 1 EA 1.02 0.51 IMA of Louisiana Commercial PPO 0.87 percent of total billed charges 0.51 0.87 Inpatient Reimbursement at 85% of Billed Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 1 EA 1.02 0.82 IMA of Louisiana Commercial PPO 0.87 percent of total billed charges 0.56 0.87 Reimbursement at 85% of billed charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 1 EA 1.02 0.82 Aetna Commercial PPO 0.56 percent of total billed charges 0.56 0.87 55 of billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC inpatient 1 EA 2.64 1.32 BCBS Louisiana PPO 1.32 percent of total billed charges 1.32 2.24 50% of Eligible Charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 BCBS Louisiana PPO 2.11 percent of total billed charges 1.45 2.24 80% of billed charge PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 Cigna Commercial PPO 1.45 percent of total billed charges 1.45 2.24 55% of Billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC inpatient 1 EA 2.64 1.32 IMA of Louisiana Commercial PPO 2.24 percent of total billed charges 1.32 2.24 Inpatient Reimbursement at 85% of Billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 IMA of Louisiana Commercial PPO 2.24 percent of total billed charges 1.45 2.24 Reimbursement at 85% of billed charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 Aetna Commercial PPO 1.45 percent of total billed charges 1.45 2.24 55 of billed Charges BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC inpatient 6 ME 222.6 111.3 BCBS Louisiana PPO 111.3 percent of total billed charges 111.3 189.21 50% of Eligible Charges BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC outpatient 6 ME 222.6 178.08 BCBS Louisiana PPO 178.08 percent of total billed charges 122.43 189.21 80% of billed charge BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC outpatient 6 ME 222.6 178.08 Cigna Commercial PPO 122.43 percent of total billed charges 122.43 189.21 55% of Billed Charges BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC inpatient 6 ME 222.6 111.3 IMA of Louisiana Commercial PPO 189.21 percent of total billed charges 111.3 189.21 Inpatient Reimbursement at 85% of Billed Charges BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC outpatient 6 ME 222.6 178.08 IMA of Louisiana Commercial PPO 189.21 percent of total billed charges 122.43 189.21 Reimbursement at 85% of billed charges BETAMETHASONE 6MG/ML 5ML 260 RC 0517072001 NDC outpatient 6 ME 222.6 178.08 Aetna Commercial PPO 122.43 percent of total billed charges 122.43 189.21 55 of billed Charges CLINDAMYCIN 900MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338411424 NDC inpatient 900 ME 39.91 19.96 BCBS Louisiana PPO 19.96 percent of total billed charges 19.96 33.92 50% of Eligible Charges CLINDAMYCIN 900MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338411424 NDC outpatient 900 ME 39.91 31.93 BCBS Louisiana PPO 31.93 percent of total billed charges 21.95 33.92 80% of billed charge CLINDAMYCIN 900MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338411424 NDC outpatient 900 ME 39.91 31.93 Cigna Commercial PPO 21.95 percent of total billed charges 21.95 33.92 55% of Billed Charges CLINDAMYCIN 900MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338411424 NDC inpatient 900 ME 39.91 19.96 IMA of Louisiana Commercial PPO 33.92 percent of total billed charges 19.96 33.92 Inpatient Reimbursement at 85% of Billed Charges CLINDAMYCIN 900MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338411424 NDC outpatient 900 ME 39.91 31.93 IMA of Louisiana Commercial PPO 33.92 percent of total billed charges 21.95 33.92 Reimbursement at 85% of billed charges GELFOAM SPONGE 100 250 RC 0009034201 NDC inpatient 1 EA 364.92 182.46 BCBS Louisiana PPO 182.46 percent of total billed charges 182.46 310.18 50% of Eligible Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 BCBS Louisiana PPO 291.94 percent of total billed charges 200.71 310.18 80% of billed charge GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 Cigna Commercial PPO 200.71 percent of total billed charges 200.71 310.18 55% of Billed Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC inpatient 1 EA 364.92 182.46 IMA of Louisiana Commercial PPO 310.18 percent of total billed charges 182.46 310.18 Inpatient Reimbursement at 85% of Billed Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 IMA of Louisiana Commercial PPO 310.18 percent of total billed charges 200.71 310.18 Reimbursement at 85% of billed charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 Aetna Commercial PPO 200.71 percent of total billed charges 200.71 310.18 55 of billed Charges BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC inpatient 4 F2 7.83 3.92 BCBS Louisiana PPO 3.92 percent of total billed charges 3.92 6.66 50% of Eligible Charges BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC outpatient 4 F2 7.83 6.26 BCBS Louisiana PPO 6.26 percent of total billed charges 4.31 6.66 80% of billed charge BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC outpatient 4 F2 7.83 6.26 Cigna Commercial PPO 4.31 percent of total billed charges 4.31 6.66 55% of Billed Charges BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC inpatient 4 F2 7.83 3.92 IMA of Louisiana Commercial PPO 6.66 percent of total billed charges 3.92 6.66 Inpatient Reimbursement at 85% of Billed Charges BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC outpatient 4 F2 7.83 6.26 IMA of Louisiana Commercial PPO 6.66 percent of total billed charges 4.31 6.66 Reimbursement at 85% of billed charges BETADINE SOLUTION 4OZ. 250 RC 6761815004 NDC outpatient 4 F2 7.83 6.26 Aetna Commercial PPO 4.31 percent of total billed charges 4.31 6.66 55 of billed Charges ENOXAPARIN 30MG/0.3ML INJ. J1650 HCPCS 250 RC 0075801310 NDC inpatient 30 ME 13.02 6.51 BCBS Louisiana PPO 6.51 percent of total billed charges 6.51 11.07 50% of Eligible Charges ENOXAPARIN 30MG/0.3ML INJ. J1650 HCPCS 250 RC 0075801310 NDC outpatient 30 ME 13.02 10.42 BCBS Louisiana PPO 10.42 percent of total billed charges 7.16 11.07 80% of billed charge ENOXAPARIN 30MG/0.3ML INJ. J1650 HCPCS 250 RC 0075801310 NDC outpatient 30 ME 13.02 10.42 Cigna Commercial PPO 7.16 percent of total billed charges 7.16 11.07 55% of Billed Charges ENOXAPARIN 30MG/0.3ML INJ. J1650 HCPCS 250 RC 0075801310 NDC inpatient 30 ME 13.02 6.51 IMA of Louisiana Commercial PPO 11.07 percent of total billed charges 6.51 11.07 Inpatient Reimbursement at 85% of Billed Charges ENOXAPARIN 30MG/0.3ML INJ. J1650 HCPCS 250 RC 0075801310 NDC outpatient 30 ME 13.02 10.42 IMA of Louisiana Commercial PPO 11.07 percent of total billed charges 7.16 11.07 Reimbursement at 85% of billed charges MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC inpatient 296 ML 14.39 7.2 BCBS Louisiana PPO 7.2 percent of total billed charges 7.2 12.23 50% of Eligible Charges MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC outpatient 296 ML 14.39 11.51 BCBS Louisiana PPO 11.51 percent of total billed charges 7.91 12.23 80% of billed charge MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC outpatient 296 ML 14.39 11.51 Cigna Commercial PPO 7.91 percent of total billed charges 7.91 12.23 55% of Billed Charges MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC inpatient 296 ML 14.39 7.2 IMA of Louisiana Commercial PPO 12.23 percent of total billed charges 7.2 12.23 Inpatient Reimbursement at 85% of Billed Charges MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC outpatient 296 ML 14.39 11.51 IMA of Louisiana Commercial PPO 12.23 percent of total billed charges 7.91 12.23 Reimbursement at 85% of billed charges MAGNESIUM CITRATE : 296ML 250 RC 5080416438 NDC outpatient 296 ML 14.39 11.51 Aetna Commercial PPO 7.91 percent of total billed charges 7.91 12.23 55 of billed Charges PROMETHAZINE 25MG TABLET J8597 HCPCS 250 RC 0904730461 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PROMETHAZINE 25MG TABLET J8597 HCPCS 250 RC 0904730461 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PROMETHAZINE 25MG TABLET J8597 HCPCS 250 RC 0904730461 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PROMETHAZINE 25MG TABLET J8597 HCPCS 250 RC 0904730461 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PROMETHAZINE 25MG TABLET J8597 HCPCS 250 RC 0904730461 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CEFTRIAXONE 1GM 10ML J0696 HCPCS 250 RC 4456770195 NDC inpatient 1 GR 6 3 BCBS Louisiana PPO 3 percent of total billed charges 3 5.1 50% of Eligible Charges CEFTRIAXONE 1GM 10ML J0696 HCPCS 250 RC 4456770195 NDC outpatient 1 GR 6 4.8 BCBS Louisiana PPO 4.8 percent of total billed charges 3.3 5.1 80% of billed charge CEFTRIAXONE 1GM 10ML J0696 HCPCS 250 RC 4456770195 NDC outpatient 1 GR 6 4.8 Cigna Commercial PPO 3.3 percent of total billed charges 3.3 5.1 55% of Billed Charges CEFTRIAXONE 1GM 10ML J0696 HCPCS 250 RC 4456770195 NDC inpatient 1 GR 6 3 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3 5.1 Inpatient Reimbursement at 85% of Billed Charges CEFTRIAXONE 1GM 10ML J0696 HCPCS 250 RC 4456770195 NDC outpatient 1 GR 6 4.8 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3.3 5.1 Reimbursement at 85% of billed charges HYDROCORTISONE 100MG/2ML VIAL J1720 HCPCS 250 RC 0009082501 NDC inpatient 100 ME 101.6 50.8 BCBS Louisiana PPO 50.8 percent of total billed charges 50.8 86.36 50% of Eligible Charges HYDROCORTISONE 100MG/2ML VIAL J1720 HCPCS 250 RC 0009082501 NDC outpatient 100 ME 101.6 81.28 BCBS Louisiana PPO 81.28 percent of total billed charges 55.88 86.36 80% of billed charge HYDROCORTISONE 100MG/2ML VIAL J1720 HCPCS 250 RC 0009082501 NDC outpatient 100 ME 101.6 81.28 Cigna Commercial PPO 55.88 percent of total billed charges 55.88 86.36 55% of Billed Charges HYDROCORTISONE 100MG/2ML VIAL J1720 HCPCS 250 RC 0009082501 NDC inpatient 100 ME 101.6 50.8 IMA of Louisiana Commercial PPO 86.36 percent of total billed charges 50.8 86.36 Inpatient Reimbursement at 85% of Billed Charges HYDROCORTISONE 100MG/2ML VIAL J1720 HCPCS 250 RC 0009082501 NDC outpatient 100 ME 101.6 81.28 IMA of Louisiana Commercial PPO 86.36 percent of total billed charges 55.88 86.36 Reimbursement at 85% of billed charges ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC inpatient 10 ME 19.41 9.71 BCBS Louisiana PPO 9.71 percent of total billed charges 9.71 16.5 50% of Eligible Charges ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC outpatient 10 ME 19.41 15.53 BCBS Louisiana PPO 15.53 percent of total billed charges 10.68 16.5 80% of billed charge ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC outpatient 10 ME 19.41 15.53 Cigna Commercial PPO 10.68 percent of total billed charges 10.68 16.5 55% of Billed Charges ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC inpatient 10 ME 19.41 9.71 IMA of Louisiana Commercial PPO 16.5 percent of total billed charges 9.71 16.5 Inpatient Reimbursement at 85% of Billed Charges ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC outpatient 10 ME 19.41 15.53 IMA of Louisiana Commercial PPO 16.5 percent of total billed charges 10.68 16.5 Reimbursement at 85% of billed charges ATRACURIUM 10MG/ML 5ML 260 RC 0409110901 NDC outpatient 10 ME 19.41 15.53 Aetna Commercial PPO 10.68 percent of total billed charges 10.68 16.5 55 of billed Charges ONDANSETRON 2MG/ML 2ML J2405 HCPCS 250 RC 2315554842 NDC inpatient 4 ME 1.39 0.7 BCBS Louisiana PPO 0.7 percent of total billed charges 0.7 1.18 50% of Eligible Charges ONDANSETRON 2MG/ML 2ML J2405 HCPCS 250 RC 2315554842 NDC outpatient 4 ME 1.39 1.11 BCBS Louisiana PPO 1.11 percent of total billed charges 0.76 1.18 80% of billed charge ONDANSETRON 2MG/ML 2ML J2405 HCPCS 250 RC 2315554842 NDC outpatient 4 ME 1.39 1.11 Cigna Commercial PPO 0.76 percent of total billed charges 0.76 1.18 55% of Billed Charges ONDANSETRON 2MG/ML 2ML J2405 HCPCS 250 RC 2315554842 NDC inpatient 4 ME 1.39 0.7 IMA of Louisiana Commercial PPO 1.18 percent of total billed charges 0.7 1.18 Inpatient Reimbursement at 85% of Billed Charges ONDANSETRON 2MG/ML 2ML J2405 HCPCS 250 RC 2315554842 NDC outpatient 4 ME 1.39 1.11 IMA of Louisiana Commercial PPO 1.18 percent of total billed charges 0.76 1.18 Reimbursement at 85% of billed charges METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC inpatient 5 ME 3.6 1.8 BCBS Louisiana PPO 1.8 percent of total billed charges 1.8 3.06 50% of Eligible Charges METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC outpatient 5 ME 3.6 2.88 BCBS Louisiana PPO 2.88 percent of total billed charges 1.98 3.06 80% of billed charge METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC outpatient 5 ME 3.6 2.88 Cigna Commercial PPO 1.98 percent of total billed charges 1.98 3.06 55% of Billed Charges METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC inpatient 5 ME 3.6 1.8 IMA of Louisiana Commercial PPO 3.06 percent of total billed charges 1.8 3.06 Inpatient Reimbursement at 85% of Billed Charges METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC outpatient 5 ME 3.6 2.88 IMA of Louisiana Commercial PPO 3.06 percent of total billed charges 1.98 3.06 Reimbursement at 85% of billed charges METOPROLOL 1MG/ML 5ML 260 RC 7261174010 NDC outpatient 5 ME 3.6 2.88 Aetna Commercial PPO 1.98 percent of total billed charges 1.98 3.06 55 of billed Charges LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC inpatient 5 ML 38.69 19.35 BCBS Louisiana PPO 19.35 percent of total billed charges 19.35 32.89 50% of Eligible Charges LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC outpatient 5 ML 38.69 30.95 BCBS Louisiana PPO 30.95 percent of total billed charges 21.28 32.89 80% of billed charge LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC outpatient 5 ML 38.69 30.95 Cigna Commercial PPO 21.28 percent of total billed charges 21.28 32.89 55% of Billed Charges LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC inpatient 5 ML 38.69 19.35 IMA of Louisiana Commercial PPO 32.89 percent of total billed charges 19.35 32.89 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC outpatient 5 ML 38.69 30.95 IMA of Louisiana Commercial PPO 32.89 percent of total billed charges 21.28 32.89 Reimbursement at 85% of billed charges LIDOCAINE 2% 5ML SYRINGE 260 RC 0409132305 NDC outpatient 5 ML 38.69 30.95 Aetna Commercial PPO 21.28 percent of total billed charges 21.28 32.89 55 of billed Charges CEFAZOLIN SDV 1GM VIAL J0690 HCPCS 250 RC 6050561425 NDC inpatient 1 GR 5.04 2.52 BCBS Louisiana PPO 2.52 percent of total billed charges 2.52 4.28 50% of Eligible Charges CEFAZOLIN SDV 1GM VIAL J0690 HCPCS 250 RC 6050561425 NDC outpatient 1 GR 5.04 4.03 BCBS Louisiana PPO 4.03 percent of total billed charges 2.77 4.28 80% of billed charge CEFAZOLIN SDV 1GM VIAL J0690 HCPCS 250 RC 6050561425 NDC outpatient 1 GR 5.04 4.03 Cigna Commercial PPO 2.77 percent of total billed charges 2.77 4.28 55% of Billed Charges CEFAZOLIN SDV 1GM VIAL J0690 HCPCS 250 RC 6050561425 NDC inpatient 1 GR 5.04 2.52 IMA of Louisiana Commercial PPO 4.28 percent of total billed charges 2.52 4.28 Inpatient Reimbursement at 85% of Billed Charges CEFAZOLIN SDV 1GM VIAL J0690 HCPCS 250 RC 6050561425 NDC outpatient 1 GR 5.04 4.03 IMA of Louisiana Commercial PPO 4.28 percent of total billed charges 2.77 4.28 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 3ML INH J7699 HCPCS 250 RC 0487930103 NDC inpatient 3 ML 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SODIUM CHL 0.9% 3ML INH J7699 HCPCS 250 RC 0487930103 NDC outpatient 3 ML 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SODIUM CHL 0.9% 3ML INH J7699 HCPCS 250 RC 0487930103 NDC outpatient 3 ML 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SODIUM CHL 0.9% 3ML INH J7699 HCPCS 250 RC 0487930103 NDC inpatient 3 ML 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 3ML INH J7699 HCPCS 250 RC 0487930103 NDC outpatient 3 ML 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LOSARTAN 50MG TABLET 250 RC 6808434701 NDC inpatient 50 ME 1.44 0.72 BCBS Louisiana PPO 0.72 percent of total billed charges 0.72 1.22 50% of Eligible Charges LOSARTAN 50MG TABLET 250 RC 6808434701 NDC outpatient 50 ME 1.44 1.15 BCBS Louisiana PPO 1.15 percent of total billed charges 0.79 1.22 80% of billed charge LOSARTAN 50MG TABLET 250 RC 6808434701 NDC outpatient 50 ME 1.44 1.15 Cigna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55% of Billed Charges LOSARTAN 50MG TABLET 250 RC 6808434701 NDC inpatient 50 ME 1.44 0.72 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.72 1.22 Inpatient Reimbursement at 85% of Billed Charges LOSARTAN 50MG TABLET 250 RC 6808434701 NDC outpatient 50 ME 1.44 1.15 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.79 1.22 Reimbursement at 85% of billed charges LOSARTAN 50MG TABLET 250 RC 6808434701 NDC outpatient 50 ME 1.44 1.15 Aetna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55 of billed Charges ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ATORVASTATIN 20MG TABLET 250 RC 6808409801 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC inpatient 30 ME 3.68 1.84 BCBS Louisiana PPO 1.84 percent of total billed charges 1.84 3.13 50% of Eligible Charges NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC outpatient 30 ME 3.68 2.94 BCBS Louisiana PPO 2.94 percent of total billed charges 2.02 3.13 80% of billed charge NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC outpatient 30 ME 3.68 2.94 Cigna Commercial PPO 2.02 percent of total billed charges 2.02 3.13 55% of Billed Charges NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC inpatient 30 ME 3.68 1.84 IMA of Louisiana Commercial PPO 3.13 percent of total billed charges 1.84 3.13 Inpatient Reimbursement at 85% of Billed Charges NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC outpatient 30 ME 3.68 2.94 IMA of Louisiana Commercial PPO 3.13 percent of total billed charges 2.02 3.13 Reimbursement at 85% of billed charges NIFEDIPINE ER 30MG TABLET 250 RC 5026859715 NDC outpatient 30 ME 3.68 2.94 Aetna Commercial PPO 2.02 percent of total billed charges 2.02 3.13 55 of billed Charges MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC inpatient 30 ME 6 3 BCBS Louisiana PPO 3 percent of total billed charges 3 5.1 50% of Eligible Charges MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC outpatient 30 ME 6 4.8 BCBS Louisiana PPO 4.8 percent of total billed charges 3.3 5.1 80% of billed charge MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC outpatient 30 ME 6 4.8 Cigna Commercial PPO 3.3 percent of total billed charges 3.3 5.1 55% of Billed Charges MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC inpatient 30 ME 6 3 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3 5.1 Inpatient Reimbursement at 85% of Billed Charges MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC outpatient 30 ME 6 4.8 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3.3 5.1 Reimbursement at 85% of billed charges MORPHINE SULF ER 30MG TAB 250 RC 6807134530 NDC outpatient 30 ME 6 4.8 Aetna Commercial PPO 3.3 percent of total billed charges 3.3 5.1 55 of billed Charges MORPHINE 10MG/ML 1ML J2270 HCPCS 250 RC 0641612725 NDC inpatient 10 ME 11.04 5.52 BCBS Louisiana PPO 5.52 percent of total billed charges 5.52 9.38 50% of Eligible Charges MORPHINE 10MG/ML 1ML J2270 HCPCS 250 RC 0641612725 NDC outpatient 10 ME 11.04 8.83 BCBS Louisiana PPO 8.83 percent of total billed charges 6.07 9.38 80% of billed charge MORPHINE 10MG/ML 1ML J2270 HCPCS 250 RC 0641612725 NDC outpatient 10 ME 11.04 8.83 Cigna Commercial PPO 6.07 percent of total billed charges 6.07 9.38 55% of Billed Charges MORPHINE 10MG/ML 1ML J2270 HCPCS 250 RC 0641612725 NDC inpatient 10 ME 11.04 5.52 IMA of Louisiana Commercial PPO 9.38 percent of total billed charges 5.52 9.38 Inpatient Reimbursement at 85% of Billed Charges MORPHINE 10MG/ML 1ML J2270 HCPCS 250 RC 0641612725 NDC outpatient 10 ME 11.04 8.83 IMA of Louisiana Commercial PPO 9.38 percent of total billed charges 6.07 9.38 Reimbursement at 85% of billed charges HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HYDROCHLOROTHIAZIDE 25MG TABLET 250 RC 6068759311 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC inpatient 1000 ML 22.46 11.23 BCBS Louisiana PPO 11.23 percent of total billed charges 11.23 19.09 50% of Eligible Charges SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC outpatient 1000 ML 22.46 17.97 BCBS Louisiana PPO 17.97 percent of total billed charges 12.35 19.09 80% of billed charge SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC outpatient 1000 ML 22.46 17.97 Cigna Commercial PPO 12.35 percent of total billed charges 12.35 19.09 55% of Billed Charges SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC inpatient 1000 ML 22.46 11.23 IMA of Louisiana Commercial PPO 19.09 percent of total billed charges 11.23 19.09 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC outpatient 1000 ML 22.46 17.97 IMA of Louisiana Commercial PPO 19.09 percent of total billed charges 12.35 19.09 Reimbursement at 85% of billed charges SODIUM CHL 0.45% 1000ML 260 RC 0264780200 NDC outpatient 1000 ML 22.46 17.97 Aetna Commercial PPO 12.35 percent of total billed charges 12.35 19.09 55 of billed Charges LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LOSARTAN/HCTZ 100/25MG TAB 250 RC 3334205207 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC inpatient 75 UN 7.49 3.75 BCBS Louisiana PPO 3.75 percent of total billed charges 3.75 6.37 50% of Eligible Charges LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC outpatient 75 UN 7.49 5.99 BCBS Louisiana PPO 5.99 percent of total billed charges 4.12 6.37 80% of billed charge LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC outpatient 75 UN 7.49 5.99 Cigna Commercial PPO 4.12 percent of total billed charges 4.12 6.37 55% of Billed Charges LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC inpatient 75 UN 7.49 3.75 IMA of Louisiana Commercial PPO 6.37 percent of total billed charges 3.75 6.37 Inpatient Reimbursement at 85% of Billed Charges LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC outpatient 75 UN 7.49 5.99 IMA of Louisiana Commercial PPO 6.37 percent of total billed charges 4.12 6.37 Reimbursement at 85% of billed charges LEVOTHYROXINE 75MCG TAB NON-FORMULARY 250 RC 5107944120 NDC outpatient 75 UN 7.49 5.99 Aetna Commercial PPO 4.12 percent of total billed charges 4.12 6.37 55 of billed Charges ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ALFUZOSIN ER 10MG TABLET 250 RC 2930015501 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC inpatient 25 ME 1.44 0.72 BCBS Louisiana PPO 0.72 percent of total billed charges 0.72 1.22 50% of Eligible Charges AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC outpatient 25 ME 1.44 1.15 BCBS Louisiana PPO 1.15 percent of total billed charges 0.79 1.22 80% of billed charge AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC outpatient 25 ME 1.44 1.15 Cigna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55% of Billed Charges AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC inpatient 25 ME 1.44 0.72 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.72 1.22 Inpatient Reimbursement at 85% of Billed Charges AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC outpatient 25 ME 1.44 1.15 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.79 1.22 Reimbursement at 85% of billed charges AMITRIPTYLINE 25MG TABLET 250 RC 6068743301 NDC outpatient 25 ME 1.44 1.15 Aetna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55 of billed Charges GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC inpatient 400 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC outpatient 400 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC outpatient 400 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC inpatient 400 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC outpatient 400 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GABAPENTIN 400MG CAPSULE 250 RC 6068760211 NDC outpatient 400 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DIPHENHYDRAMINE 25MG CAPSULE 250 RC 0904723760 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC inpatient 20 ME 2.35 1.18 BCBS Louisiana PPO 1.18 percent of total billed charges 1.18 2 50% of Eligible Charges PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC outpatient 20 ME 2.35 1.88 BCBS Louisiana PPO 1.88 percent of total billed charges 1.29 2 80% of billed charge PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC outpatient 20 ME 2.35 1.88 Cigna Commercial PPO 1.29 percent of total billed charges 1.29 2 55% of Billed Charges PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC inpatient 20 ME 2.35 1.18 IMA of Louisiana Commercial PPO 2 percent of total billed charges 1.18 2 Inpatient Reimbursement at 85% of Billed Charges PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC outpatient 20 ME 2.35 1.88 IMA of Louisiana Commercial PPO 2 percent of total billed charges 1.29 2 Reimbursement at 85% of billed charges PRAVASTATIN 20MG TABLET 250 RC 0904589261 NDC outpatient 20 ME 2.35 1.88 Aetna Commercial PPO 1.29 percent of total billed charges 1.29 2 55 of billed Charges FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC inpatient 25 UN 26.94 13.47 BCBS Louisiana PPO 13.47 percent of total billed charges 13.47 22.9 50% of Eligible Charges FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC outpatient 25 UN 26.94 21.55 BCBS Louisiana PPO 21.55 percent of total billed charges 14.82 22.9 80% of billed charge FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC outpatient 25 UN 26.94 21.55 Cigna Commercial PPO 14.82 percent of total billed charges 14.82 22.9 55% of Billed Charges FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC inpatient 25 UN 26.94 13.47 IMA of Louisiana Commercial PPO 22.9 percent of total billed charges 13.47 22.9 Inpatient Reimbursement at 85% of Billed Charges FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC outpatient 25 UN 26.94 21.55 IMA of Louisiana Commercial PPO 22.9 percent of total billed charges 14.82 22.9 Reimbursement at 85% of billed charges FENTANYL 25MCG/HR PATCH 250 RC 4778142447 NDC outpatient 25 UN 26.94 21.55 Aetna Commercial PPO 14.82 percent of total billed charges 14.82 22.9 55 of billed Charges MORPHINE 1MG/ML PCA 50ML J2274 HCPCS 261 RC 0409381512 NDC inpatient 1 ME 374.28 187.14 BCBS Louisiana PPO 187.14 percent of total billed charges 187.14 318.14 50% of Eligible Charges MORPHINE 1MG/ML PCA 50ML J2274 HCPCS 261 RC 0409381512 NDC outpatient 1 ME 374.28 299.42 BCBS Louisiana PPO 299.42 percent of total billed charges 205.85 318.14 80% of billed charge MORPHINE 1MG/ML PCA 50ML J2274 HCPCS 261 RC 0409381512 NDC outpatient 1 ME 374.28 299.42 Cigna Commercial PPO 205.85 percent of total billed charges 205.85 318.14 55% of Billed Charges MORPHINE 1MG/ML PCA 50ML J2274 HCPCS 261 RC 0409381512 NDC inpatient 1 ME 374.28 187.14 IMA of Louisiana Commercial PPO 318.14 percent of total billed charges 187.14 318.14 Inpatient Reimbursement at 85% of Billed Charges MORPHINE 1MG/ML PCA 50ML J2274 HCPCS 261 RC 0409381512 NDC outpatient 1 ME 374.28 299.42 IMA of Louisiana Commercial PPO 318.14 percent of total billed charges 205.85 318.14 Reimbursement at 85% of billed charges WARFARIN 2MG TABLET 250 RC 0832121289 NDC inpatient 2 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges WARFARIN 2MG TABLET 250 RC 0832121289 NDC outpatient 2 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge WARFARIN 2MG TABLET 250 RC 0832121289 NDC outpatient 2 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges WARFARIN 2MG TABLET 250 RC 0832121289 NDC inpatient 2 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges WARFARIN 2MG TABLET 250 RC 0832121289 NDC outpatient 2 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges WARFARIN 2MG TABLET 250 RC 0832121289 NDC outpatient 2 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LINEZOLID 600MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0093824419 NDC inpatient 600 ME 8.33 4.17 BCBS Louisiana PPO 4.17 percent of total billed charges 4.17 7.08 50% of Eligible Charges LINEZOLID 600MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0093824419 NDC outpatient 600 ME 8.33 6.66 BCBS Louisiana PPO 6.66 percent of total billed charges 4.58 7.08 80% of billed charge LINEZOLID 600MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0093824419 NDC outpatient 600 ME 8.33 6.66 Cigna Commercial PPO 4.58 percent of total billed charges 4.58 7.08 55% of Billed Charges LINEZOLID 600MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0093824419 NDC inpatient 600 ME 8.33 4.17 IMA of Louisiana Commercial PPO 7.08 percent of total billed charges 4.17 7.08 Inpatient Reimbursement at 85% of Billed Charges LINEZOLID 600MG TABLET NON-FORMULARY J8499 HCPCS 250 RC 0093824419 NDC outpatient 600 ME 8.33 6.66 IMA of Louisiana Commercial PPO 7.08 percent of total billed charges 4.58 7.08 Reimbursement at 85% of billed charges ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ENALAPRIL 10MG TABLET 250 RC 4354754710 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC inpatient 2.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC outpatient 2.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC outpatient 2.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC inpatient 2.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC outpatient 2.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GLYBURIDE 2.5MG TABLET 250 RC 0093834301 NDC outpatient 2.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC inpatient 5 ME 2.06 1.03 BCBS Louisiana PPO 1.03 percent of total billed charges 1.03 1.75 50% of Eligible Charges RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC outpatient 5 ME 2.06 1.65 BCBS Louisiana PPO 1.65 percent of total billed charges 1.13 1.75 80% of billed charge RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC outpatient 5 ME 2.06 1.65 Cigna Commercial PPO 1.13 percent of total billed charges 1.13 1.75 55% of Billed Charges RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC inpatient 5 ME 2.06 1.03 IMA of Louisiana Commercial PPO 1.75 percent of total billed charges 1.03 1.75 Inpatient Reimbursement at 85% of Billed Charges RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC outpatient 5 ME 2.06 1.65 IMA of Louisiana Commercial PPO 1.75 percent of total billed charges 1.13 1.75 Reimbursement at 85% of billed charges RAMIPRIL 5MG CAPSULE 250 RC 6818059001 NDC outpatient 5 ME 2.06 1.65 Aetna Commercial PPO 1.13 percent of total billed charges 1.13 1.75 55 of billed Charges GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GABAPENTIN 100MG CAPSULE 250 RC 6068758011 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges "HEPARIN SODIUM 5,000U/ML 1ML INJ NON-FOR" J1644 HCPCS 250 RC 2502140201 NDC inpatient 1 ML 6.45 3.23 BCBS Louisiana PPO 3.23 percent of total billed charges 3.23 5.48 50% of Eligible Charges "HEPARIN SODIUM 5,000U/ML 1ML INJ NON-FOR" J1644 HCPCS 250 RC 2502140201 NDC outpatient 1 ML 6.45 5.16 BCBS Louisiana PPO 5.16 percent of total billed charges 3.55 5.48 80% of billed charge "HEPARIN SODIUM 5,000U/ML 1ML INJ NON-FOR" J1644 HCPCS 250 RC 2502140201 NDC outpatient 1 ML 6.45 5.16 Cigna Commercial PPO 3.55 percent of total billed charges 3.55 5.48 55% of Billed Charges "HEPARIN SODIUM 5,000U/ML 1ML INJ NON-FOR" J1644 HCPCS 250 RC 2502140201 NDC inpatient 1 ML 6.45 3.23 IMA of Louisiana Commercial PPO 5.48 percent of total billed charges 3.23 5.48 Inpatient Reimbursement at 85% of Billed Charges "HEPARIN SODIUM 5,000U/ML 1ML INJ NON-FOR" J1644 HCPCS 250 RC 2502140201 NDC outpatient 1 ML 6.45 5.16 IMA of Louisiana Commercial PPO 5.48 percent of total billed charges 3.55 5.48 Reimbursement at 85% of billed charges METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC inpatient 500 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC outpatient 500 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC outpatient 500 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC inpatient 500 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC outpatient 500 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METHOCARBAMOL 500MG TABLET 250 RC 6068755911 NDC outpatient 500 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges METHADONE 10MG TABLET 250 RC 0406577162 NDC inpatient 10 ME 2.1 1.05 BCBS Louisiana PPO 1.05 percent of total billed charges 1.05 1.79 50% of Eligible Charges METHADONE 10MG TABLET 250 RC 0406577162 NDC outpatient 10 ME 2.1 1.68 BCBS Louisiana PPO 1.68 percent of total billed charges 1.16 1.79 80% of billed charge METHADONE 10MG TABLET 250 RC 0406577162 NDC outpatient 10 ME 2.1 1.68 Cigna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55% of Billed Charges METHADONE 10MG TABLET 250 RC 0406577162 NDC inpatient 10 ME 2.1 1.05 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.05 1.79 Inpatient Reimbursement at 85% of Billed Charges METHADONE 10MG TABLET 250 RC 0406577162 NDC outpatient 10 ME 2.1 1.68 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.16 1.79 Reimbursement at 85% of billed charges METHADONE 10MG TABLET 250 RC 0406577162 NDC outpatient 10 ME 2.1 1.68 Aetna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55 of billed Charges FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FOSINOPRIL 20MG TABLET 250 RC 4354738709 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CHL 0.9% 500ML J7040 HCPCS 260 RC 0264780010 NDC inpatient 500 ML 23.44 11.72 BCBS Louisiana PPO 11.72 percent of total billed charges 11.72 19.92 50% of Eligible Charges SODIUM CHL 0.9% 500ML J7040 HCPCS 260 RC 0264780010 NDC outpatient 500 ML 23.44 18.75 BCBS Louisiana PPO 18.75 percent of total billed charges 12.89 19.92 80% of billed charge SODIUM CHL 0.9% 500ML J7040 HCPCS 260 RC 0264780010 NDC outpatient 500 ML 23.44 18.75 Cigna Commercial PPO 12.89 percent of total billed charges 12.89 19.92 55% of Billed Charges SODIUM CHL 0.9% 500ML J7040 HCPCS 260 RC 0264780010 NDC inpatient 500 ML 23.44 11.72 IMA of Louisiana Commercial PPO 19.92 percent of total billed charges 11.72 19.92 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 500ML J7040 HCPCS 260 RC 0264780010 NDC outpatient 500 ML 23.44 18.75 IMA of Louisiana Commercial PPO 19.92 percent of total billed charges 12.89 19.92 Reimbursement at 85% of billed charges LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC inpatient 3 ML 105.98 52.99 BCBS Louisiana PPO 52.99 percent of total billed charges 52.99 90.08 50% of Eligible Charges LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC outpatient 3 ML 105.98 84.78 BCBS Louisiana PPO 84.78 percent of total billed charges 58.29 90.08 80% of billed charge LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC outpatient 3 ML 105.98 84.78 Cigna Commercial PPO 58.29 percent of total billed charges 58.29 90.08 55% of Billed Charges LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC inpatient 3 ML 105.98 52.99 IMA of Louisiana Commercial PPO 90.08 percent of total billed charges 52.99 90.08 Inpatient Reimbursement at 85% of Billed Charges LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC outpatient 3 ML 105.98 84.78 IMA of Louisiana Commercial PPO 90.08 percent of total billed charges 58.29 90.08 Reimbursement at 85% of billed charges LANTUS 100U/ML 3ML SYRINGE J0815 CPT 250 RC 0088221905 NDC outpatient 3 ML 105.98 84.78 Aetna Commercial PPO 58.29 percent of total billed charges 58.29 90.08 55 of billed Charges ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ROPINIROLE 0.5MG TABLET 250 RC 6945235720 NDC outpatient 0.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC inpatient 1 EA 2.64 1.32 BCBS Louisiana PPO 1.32 percent of total billed charges 1.32 2.24 50% of Eligible Charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 BCBS Louisiana PPO 2.11 percent of total billed charges 1.45 2.24 80% of billed charge PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 Cigna Commercial PPO 1.45 percent of total billed charges 1.45 2.24 55% of Billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC inpatient 1 EA 2.64 1.32 IMA of Louisiana Commercial PPO 2.24 percent of total billed charges 1.32 2.24 Inpatient Reimbursement at 85% of Billed Charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 IMA of Louisiana Commercial PPO 2.24 percent of total billed charges 1.45 2.24 Reimbursement at 85% of billed charges PSYLLIUM PACKET 250 RC 3700002410 NDC outpatient 1 EA 2.64 2.11 Aetna Commercial PPO 1.45 percent of total billed charges 1.45 2.24 55 of billed Charges FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC inpatient 50 UN 36.12 18.06 BCBS Louisiana PPO 18.06 percent of total billed charges 18.06 30.7 50% of Eligible Charges FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC outpatient 50 UN 36.12 28.9 BCBS Louisiana PPO 28.9 percent of total billed charges 19.87 30.7 80% of billed charge FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC outpatient 50 UN 36.12 28.9 Cigna Commercial PPO 19.87 percent of total billed charges 19.87 30.7 55% of Billed Charges FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC inpatient 50 UN 36.12 18.06 IMA of Louisiana Commercial PPO 30.7 percent of total billed charges 18.06 30.7 Inpatient Reimbursement at 85% of Billed Charges FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC outpatient 50 UN 36.12 28.9 IMA of Louisiana Commercial PPO 30.7 percent of total billed charges 19.87 30.7 Reimbursement at 85% of billed charges FLONASE 50MCG NASAL SPRAY 250 RC 6050508291 NDC outpatient 50 UN 36.12 28.9 Aetna Commercial PPO 19.87 percent of total billed charges 19.87 30.7 55 of billed Charges MICAFUNGIN 100MG/100ML IVPB NON-FORM J2248 HCPCS 260 RC 6332372912 NDC inpatient 100 ML 59.87 29.94 BCBS Louisiana PPO 29.94 percent of total billed charges 29.94 50.89 50% of Eligible Charges MICAFUNGIN 100MG/100ML IVPB NON-FORM J2248 HCPCS 260 RC 6332372912 NDC outpatient 100 ML 59.87 47.9 BCBS Louisiana PPO 47.9 percent of total billed charges 32.93 50.89 80% of billed charge MICAFUNGIN 100MG/100ML IVPB NON-FORM J2248 HCPCS 260 RC 6332372912 NDC outpatient 100 ML 59.87 47.9 Cigna Commercial PPO 32.93 percent of total billed charges 32.93 50.89 55% of Billed Charges MICAFUNGIN 100MG/100ML IVPB NON-FORM J2248 HCPCS 260 RC 6332372912 NDC inpatient 100 ML 59.87 29.94 IMA of Louisiana Commercial PPO 50.89 percent of total billed charges 29.94 50.89 Inpatient Reimbursement at 85% of Billed Charges MICAFUNGIN 100MG/100ML IVPB NON-FORM J2248 HCPCS 260 RC 6332372912 NDC outpatient 100 ML 59.87 47.9 IMA of Louisiana Commercial PPO 50.89 percent of total billed charges 32.93 50.89 Reimbursement at 85% of billed charges DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC inpatient 25 ME 3.03 1.52 BCBS Louisiana PPO 1.52 percent of total billed charges 1.52 2.58 50% of Eligible Charges DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC outpatient 25 ME 3.03 2.42 BCBS Louisiana PPO 2.42 percent of total billed charges 1.67 2.58 80% of billed charge DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC outpatient 25 ME 3.03 2.42 Cigna Commercial PPO 1.67 percent of total billed charges 1.67 2.58 55% of Billed Charges DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC inpatient 25 ME 3.03 1.52 IMA of Louisiana Commercial PPO 2.58 percent of total billed charges 1.52 2.58 Inpatient Reimbursement at 85% of Billed Charges DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC outpatient 25 ME 3.03 2.42 IMA of Louisiana Commercial PPO 2.58 percent of total billed charges 1.67 2.58 Reimbursement at 85% of billed charges DOXEPIN 25MG CAPSULE 250 RC 5107943701 NDC outpatient 25 ME 3.03 2.42 Aetna Commercial PPO 1.67 percent of total billed charges 1.67 2.58 55 of billed Charges JANUVIA 50MG TABLET 250 RC 0006011231 NDC inpatient 50 ME 63.36 31.68 BCBS Louisiana PPO 31.68 percent of total billed charges 31.68 53.86 50% of Eligible Charges JANUVIA 50MG TABLET 250 RC 0006011231 NDC outpatient 50 ME 63.36 50.69 BCBS Louisiana PPO 50.69 percent of total billed charges 34.85 53.86 80% of billed charge JANUVIA 50MG TABLET 250 RC 0006011231 NDC outpatient 50 ME 63.36 50.69 Cigna Commercial PPO 34.85 percent of total billed charges 34.85 53.86 55% of Billed Charges JANUVIA 50MG TABLET 250 RC 0006011231 NDC inpatient 50 ME 63.36 31.68 IMA of Louisiana Commercial PPO 53.86 percent of total billed charges 31.68 53.86 Inpatient Reimbursement at 85% of Billed Charges JANUVIA 50MG TABLET 250 RC 0006011231 NDC outpatient 50 ME 63.36 50.69 IMA of Louisiana Commercial PPO 53.86 percent of total billed charges 34.85 53.86 Reimbursement at 85% of billed charges JANUVIA 50MG TABLET 250 RC 0006011231 NDC outpatient 50 ME 63.36 50.69 Aetna Commercial PPO 34.85 percent of total billed charges 34.85 53.86 55 of billed Charges SENNA TABS 250 RC 6761830010 NDC inpatient 8.6 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SENNA TABS 250 RC 6761830010 NDC outpatient 8.6 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SENNA TABS 250 RC 6761830010 NDC outpatient 8.6 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SENNA TABS 250 RC 6761830010 NDC inpatient 8.6 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SENNA TABS 250 RC 6761830010 NDC outpatient 8.6 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SENNA TABS 250 RC 6761830010 NDC outpatient 8.6 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC inpatient 2 ME 3.27 1.64 BCBS Louisiana PPO 1.64 percent of total billed charges 1.64 2.78 50% of Eligible Charges DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC outpatient 2 ME 3.27 2.62 BCBS Louisiana PPO 2.62 percent of total billed charges 1.8 2.78 80% of billed charge DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC outpatient 2 ME 3.27 2.62 Cigna Commercial PPO 1.8 percent of total billed charges 1.8 2.78 55% of Billed Charges DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC inpatient 2 ME 3.27 1.64 IMA of Louisiana Commercial PPO 2.78 percent of total billed charges 1.64 2.78 Inpatient Reimbursement at 85% of Billed Charges DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC outpatient 2 ME 3.27 2.62 IMA of Louisiana Commercial PPO 2.78 percent of total billed charges 1.8 2.78 Reimbursement at 85% of billed charges DEXAMETHASONE 2MG TAB NON-FORMULARY 250 RC 0904744461 NDC outpatient 2 ME 3.27 2.62 Aetna Commercial PPO 1.8 percent of total billed charges 1.8 2.78 55 of billed Charges BUPIVACAINE 0.25% 50ML J3490 HCPCS 250 RC 5515024950 NDC inpatient 50 ML 11.17 5.59 BCBS Louisiana PPO 5.59 percent of total billed charges 5.59 9.49 50% of Eligible Charges BUPIVACAINE 0.25% 50ML J3490 HCPCS 250 RC 5515024950 NDC outpatient 50 ML 11.17 8.94 BCBS Louisiana PPO 8.94 percent of total billed charges 6.14 9.49 80% of billed charge BUPIVACAINE 0.25% 50ML J3490 HCPCS 250 RC 5515024950 NDC outpatient 50 ML 11.17 8.94 Cigna Commercial PPO 6.14 percent of total billed charges 6.14 9.49 55% of Billed Charges BUPIVACAINE 0.25% 50ML J3490 HCPCS 250 RC 5515024950 NDC inpatient 50 ML 11.17 5.59 IMA of Louisiana Commercial PPO 9.49 percent of total billed charges 5.59 9.49 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.25% 50ML J3490 HCPCS 250 RC 5515024950 NDC outpatient 50 ML 11.17 8.94 IMA of Louisiana Commercial PPO 9.49 percent of total billed charges 6.14 9.49 Reimbursement at 85% of billed charges AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC inpatient 250 ME 1.1 0.55 BCBS Louisiana PPO 0.55 percent of total billed charges 0.55 0.94 50% of Eligible Charges AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC outpatient 250 ME 1.1 0.88 BCBS Louisiana PPO 0.88 percent of total billed charges 0.61 0.94 80% of billed charge AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC outpatient 250 ME 1.1 0.88 Cigna Commercial PPO 0.61 percent of total billed charges 0.61 0.94 55% of Billed Charges AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC inpatient 250 ME 1.1 0.55 IMA of Louisiana Commercial PPO 0.94 percent of total billed charges 0.55 0.94 Inpatient Reimbursement at 85% of Billed Charges AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC outpatient 250 ME 1.1 0.88 IMA of Louisiana Commercial PPO 0.94 percent of total billed charges 0.61 0.94 Reimbursement at 85% of billed charges AZITHROMYCIN 250MG TAB 250 RC 6818086111 NDC outpatient 250 ME 1.1 0.88 Aetna Commercial PPO 0.61 percent of total billed charges 0.61 0.94 55 of billed Charges BUPIVACAINE 0.5% 10ML J3490 HCPCS 250 RC 5515016910 NDC inpatient 10 ML 9.55 4.78 BCBS Louisiana PPO 4.78 percent of total billed charges 4.78 8.12 50% of Eligible Charges BUPIVACAINE 0.5% 10ML J3490 HCPCS 250 RC 5515016910 NDC outpatient 10 ML 9.55 7.64 BCBS Louisiana PPO 7.64 percent of total billed charges 5.25 8.12 80% of billed charge BUPIVACAINE 0.5% 10ML J3490 HCPCS 250 RC 5515016910 NDC outpatient 10 ML 9.55 7.64 Cigna Commercial PPO 5.25 percent of total billed charges 5.25 8.12 55% of Billed Charges BUPIVACAINE 0.5% 10ML J3490 HCPCS 250 RC 5515016910 NDC inpatient 10 ML 9.55 4.78 IMA of Louisiana Commercial PPO 8.12 percent of total billed charges 4.78 8.12 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.5% 10ML J3490 HCPCS 250 RC 5515016910 NDC outpatient 10 ML 9.55 7.64 IMA of Louisiana Commercial PPO 8.12 percent of total billed charges 5.25 8.12 Reimbursement at 85% of billed charges LIPOFEN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 6686914730 NDC inpatient 150 ME 19.04 9.52 BCBS Louisiana PPO 9.52 percent of total billed charges 9.52 16.18 50% of Eligible Charges LIPOFEN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 6686914730 NDC outpatient 150 ME 19.04 15.23 BCBS Louisiana PPO 15.23 percent of total billed charges 10.47 16.18 80% of billed charge LIPOFEN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 6686914730 NDC outpatient 150 ME 19.04 15.23 Cigna Commercial PPO 10.47 percent of total billed charges 10.47 16.18 55% of Billed Charges LIPOFEN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 6686914730 NDC inpatient 150 ME 19.04 9.52 IMA of Louisiana Commercial PPO 16.18 percent of total billed charges 9.52 16.18 Inpatient Reimbursement at 85% of Billed Charges LIPOFEN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 6686914730 NDC outpatient 150 ME 19.04 15.23 IMA of Louisiana Commercial PPO 16.18 percent of total billed charges 10.47 16.18 Reimbursement at 85% of billed charges BUPIVACAINE 0.25% W/EPI 50ML J3490 HCPCS 250 RC 0409175250 NDC inpatient 50 ML 30.48 15.24 BCBS Louisiana PPO 15.24 percent of total billed charges 15.24 25.91 50% of Eligible Charges BUPIVACAINE 0.25% W/EPI 50ML J3490 HCPCS 250 RC 0409175250 NDC outpatient 50 ML 30.48 24.38 BCBS Louisiana PPO 24.38 percent of total billed charges 16.76 25.91 80% of billed charge BUPIVACAINE 0.25% W/EPI 50ML J3490 HCPCS 250 RC 0409175250 NDC outpatient 50 ML 30.48 24.38 Cigna Commercial PPO 16.76 percent of total billed charges 16.76 25.91 55% of Billed Charges BUPIVACAINE 0.25% W/EPI 50ML J3490 HCPCS 250 RC 0409175250 NDC inpatient 50 ML 30.48 15.24 IMA of Louisiana Commercial PPO 25.91 percent of total billed charges 15.24 25.91 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.25% W/EPI 50ML J3490 HCPCS 250 RC 0409175250 NDC outpatient 50 ML 30.48 24.38 IMA of Louisiana Commercial PPO 25.91 percent of total billed charges 16.76 25.91 Reimbursement at 85% of billed charges ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC inpatient 0.4 ME 36 18 BCBS Louisiana PPO 18 percent of total billed charges 18 30.6 50% of Eligible Charges ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC outpatient 0.4 ME 36 28.8 BCBS Louisiana PPO 28.8 percent of total billed charges 19.8 30.6 80% of billed charge ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC outpatient 0.4 ME 36 28.8 Cigna Commercial PPO 19.8 percent of total billed charges 19.8 30.6 55% of Billed Charges ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC inpatient 0.4 ME 36 18 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 18 30.6 Inpatient Reimbursement at 85% of Billed Charges ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC outpatient 0.4 ME 36 28.8 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 19.8 30.6 Reimbursement at 85% of billed charges ATROPINE 0.4MG/ML 20ML INJ. 260 RC 0641600601 NDC outpatient 0.4 ME 36 28.8 Aetna Commercial PPO 19.8 percent of total billed charges 19.8 30.6 55 of billed Charges TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TAMOXIFEN 10MG TABLET 250 RC 0591247260 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC inpatient 5 ME 75.69 37.85 BCBS Louisiana PPO 37.85 percent of total billed charges 37.85 64.34 50% of Eligible Charges DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC outpatient 5 ME 75.69 60.55 BCBS Louisiana PPO 60.55 percent of total billed charges 41.63 64.34 80% of billed charge DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC outpatient 5 ME 75.69 60.55 Cigna Commercial PPO 41.63 percent of total billed charges 41.63 64.34 55% of Billed Charges DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC inpatient 5 ME 75.69 37.85 IMA of Louisiana Commercial PPO 64.34 percent of total billed charges 37.85 64.34 Inpatient Reimbursement at 85% of Billed Charges DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC outpatient 5 ME 75.69 60.55 IMA of Louisiana Commercial PPO 64.34 percent of total billed charges 41.63 64.34 Reimbursement at 85% of billed charges DAPAGLIFLOZIN 5MG TABLET 250 RC 0310620530 NDC outpatient 5 ME 75.69 60.55 Aetna Commercial PPO 41.63 percent of total billed charges 41.63 64.34 55 of billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC inpatient 1 EA 12.3 6.15 BCBS Louisiana PPO 6.15 percent of total billed charges 6.15 10.46 50% of Eligible Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 BCBS Louisiana PPO 9.84 percent of total billed charges 6.77 10.46 80% of billed charge BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 Cigna Commercial PPO 6.77 percent of total billed charges 6.77 10.46 55% of Billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC inpatient 1 EA 12.3 6.15 IMA of Louisiana Commercial PPO 10.46 percent of total billed charges 6.15 10.46 Inpatient Reimbursement at 85% of Billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 IMA of Louisiana Commercial PPO 10.46 percent of total billed charges 6.77 10.46 Reimbursement at 85% of billed charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 Aetna Commercial PPO 6.77 percent of total billed charges 6.77 10.46 55 of billed Charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC inpatient 4430.75 2215.38 BCBS Louisiana PPO 2215.38 percent of total billed charges 2215.38 3766.14 50% of Eligible Charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC outpatient 4430.75 3544.6 BCBS Louisiana PPO 3544.6 percent of total billed charges 1300 3766.14 80% of billed charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC outpatient 4430.75 3544.6 Cigna Commercial PPO 2436.91 percent of total billed charges 1300 3766.14 55% of Billed Charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC inpatient 4430.75 2215.38 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 2215.38 3766.14 Inpatient Reimbursement at 85% of Billed Charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC outpatient 4430.75 3544.6 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 1300 3766.14 Reimbursement at 85% of billed charges DX INNERVUE ARTHROSCOPY SHOULDER 29805 CPT 360 RC outpatient 4430.75 3544.6 Aetna Commercial PPO 1300 fee schedule 1300 3766.14 Case Rate NECK SPINE DISK SURGERY 63020 CPT 360 RC inpatient 13735.73 6867.87 BCBS Louisiana PPO 6867.87 percent of total billed charges 6867.87 11675.37 50% of Eligible Charges NECK SPINE DISK SURGERY 63020 CPT 360 RC outpatient 13735.73 10988.58 BCBS Louisiana PPO 10988.58 percent of total billed charges 1300 11675.37 80% of billed charges NECK SPINE DISK SURGERY 63020 CPT 360 RC outpatient 13735.73 10988.58 Cigna Commercial PPO 6800 case rate 1300 11675.37 6800 case rate NECK SPINE DISK SURGERY 63020 CPT 360 RC inpatient 13735.73 6867.87 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 6867.87 11675.37 Inpatient Reimbursement at 85% of Billed Charges NECK SPINE DISK SURGERY 63020 CPT 360 RC outpatient 13735.73 10988.58 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 1300 11675.37 Reimbursement at 85% of billed charges NECK SPINE DISK SURGERY 63020 CPT 360 RC outpatient 13735.73 10988.58 Aetna Commercial PPO 1300 fee schedule 1300 11675.37 Case Rate SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC inpatient 9704.1 4852.05 BCBS Louisiana PPO 4852.05 percent of total billed charges 4852.05 8248.49 50% of Eligible Charges SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC outpatient 9704.1 7763.28 BCBS Louisiana PPO 7763.28 percent of total billed charges 1300 8248.49 80% of billed charges SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC outpatient 9704.1 7763.28 Cigna Commercial PPO 6800 case rate 1300 8248.49 6800 case rate SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC inpatient 9704.1 4852.05 IMA of Louisiana Commercial PPO 8248.49 percent of total billed charges 4852.05 8248.49 Inpatient Reimbursement at 85% of Billed Charges SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC outpatient 9704.1 7763.28 IMA of Louisiana Commercial PPO 8248.49 percent of total billed charges 1300 8248.49 Reimbursement at 85% of billed charges SPINAL DISK SURGERY ADD-ON 63035 CPT 360 RC outpatient 9704.1 7763.28 Aetna Commercial PPO 1300 fee schedule 1300 8248.49 Case Rate REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC inpatient 9704.1 4852.05 BCBS Louisiana PPO 4852.05 percent of total billed charges 4852.05 8248.49 50% of Eligible Charges REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC outpatient 9704.1 7763.28 BCBS Louisiana PPO 7763.28 percent of total billed charges 1300 8248.49 80% of billed charges REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC outpatient 9704.1 7763.28 Cigna Commercial PPO 6800 case rate 1300 8248.49 6800 case rate REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC inpatient 9704.1 4852.05 IMA of Louisiana Commercial PPO 8248.49 percent of total billed charges 4852.05 8248.49 Inpatient Reimbursement at 85% of Billed Charges REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC outpatient 9704.1 7763.28 IMA of Louisiana Commercial PPO 8248.49 percent of total billed charges 1300 8248.49 Reimbursement at 85% of billed charges REMOVE SPINAL LAMINA ADD-ON 63048 CPT 360 RC outpatient 9704.1 7763.28 Aetna Commercial PPO 1300 fee schedule 1300 8248.49 Case Rate REVISE ARM/LEG NERVE 64708 CPT 360 RC inpatient 3422.33 1711.17 BCBS Louisiana PPO 1711.17 percent of total billed charges 1711.17 2908.98 50% of Eligible Charges REVISE ARM/LEG NERVE 64708 CPT 360 RC outpatient 3422.33 2737.86 BCBS Louisiana PPO 2737.86 percent of total billed charges 1300 2908.98 80% of billed charges REVISE ARM/LEG NERVE 64708 CPT 360 RC outpatient 3422.33 2737.86 Cigna Commercial PPO 1882.28 percent of total billed charges 1300 2908.98 55% of Billed Charges REVISE ARM/LEG NERVE 64708 CPT 360 RC inpatient 3422.33 1711.17 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1711.17 2908.98 Inpatient Reimbursement at 85% of Billed Charges REVISE ARM/LEG NERVE 64708 CPT 360 RC outpatient 3422.33 2737.86 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1300 2908.98 Reimbursement at 85% of billed charges REVISE ARM/LEG NERVE 64708 CPT 360 RC outpatient 3422.33 2737.86 Aetna Commercial PPO 1300 fee schedule 1300 2908.98 Case Rate REPAIR OF DIGIT NERVE 64831 CPT 360 RC inpatient 9833.63 4916.82 BCBS Louisiana PPO 4916.82 percent of total billed charges 4916.82 8358.59 50% of Eligible Charges REPAIR OF DIGIT NERVE 64831 CPT 360 RC outpatient 9833.63 7866.9 BCBS Louisiana PPO 7866.9 percent of total billed charges 1300 8358.59 80% of billed charges REPAIR OF DIGIT NERVE 64831 CPT 360 RC outpatient 9833.63 7866.9 Cigna Commercial PPO 5408.5 percent of total billed charges 1300 8358.59 55% of Billed Charges REPAIR OF DIGIT NERVE 64831 CPT 360 RC inpatient 9833.63 4916.82 IMA of Louisiana Commercial PPO 8358.59 percent of total billed charges 4916.82 8358.59 Inpatient Reimbursement at 85% of Billed Charges REPAIR OF DIGIT NERVE 64831 CPT 360 RC outpatient 9833.63 7866.9 IMA of Louisiana Commercial PPO 8358.59 percent of total billed charges 1300 8358.59 Reimbursement at 85% of billed charges REPAIR OF DIGIT NERVE 64831 CPT 360 RC outpatient 9833.63 7866.9 Aetna Commercial PPO 1300 fee schedule 1300 8358.59 Case Rate SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC inpatient 8792.43 4396.22 BCBS Louisiana PPO 4396.22 percent of total billed charges 4396.22 7473.57 50% of Eligible Charges SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC outpatient 8792.43 7033.94 BCBS Louisiana PPO 7033.94 percent of total billed charges 1300 7473.57 80% of billed charges SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC outpatient 8792.43 7033.94 Cigna Commercial PPO 4835.84 percent of total billed charges 1300 7473.57 55% of Billed Charges SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC inpatient 8792.43 4396.22 IMA of Louisiana Commercial PPO 7473.57 percent of total billed charges 4396.22 7473.57 Inpatient Reimbursement at 85% of Billed Charges SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC outpatient 8792.43 7033.94 IMA of Louisiana Commercial PPO 7473.57 percent of total billed charges 1300 7473.57 Reimbursement at 85% of billed charges SUTURE OF MAJOR PERIPHERAL NERVE ARM/LEG 64857 CPT 360 RC outpatient 8792.43 7033.94 Aetna Commercial PPO 1300 fee schedule 1300 7473.57 Case Rate EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC inpatient 3952.93 1976.47 BCBS Louisiana PPO 1976.47 percent of total billed charges 1976.47 3359.99 50% of Eligible Charges EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC outpatient 3952.93 3162.34 BCBS Louisiana PPO 3162.34 percent of total billed charges 1300 3359.99 80% of billed charges EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC outpatient 3952.93 3162.34 Cigna Commercial PPO 2174.11 percent of total billed charges 1300 3359.99 55% of Billed Charges EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC inpatient 3952.93 1976.47 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1976.47 3359.99 Inpatient Reimbursement at 85% of Billed Charges EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC outpatient 3952.93 3162.34 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1300 3359.99 Reimbursement at 85% of billed charges EXCISION OF NEUROMA DIGITAL NERVE EACH 64778 CPT 360 RC outpatient 3952.93 3162.34 Aetna Commercial PPO 1300 fee schedule 1300 3359.99 Case Rate INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges INJ DX OR THERAPEUTIC FACET CERV OR THOR 64490 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC inpatient 1208 604 BCBS Louisiana PPO 604 percent of total billed charges 604 1026.8 50% of Eligible Charges INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC outpatient 1208 966.4 BCBS Louisiana PPO 966.4 percent of total billed charges 664.4 1300 80% of billed charges INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC outpatient 1208 966.4 Cigna Commercial PPO 664.4 percent of total billed charges 664.4 1300 55% of Billed Charges INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC inpatient 1208 604 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 604 1026.8 Inpatient Reimbursement at 85% of Billed Charges INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC outpatient 1208 966.4 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 664.4 1300 Reimbursement at 85% of billed charges INJ DX OR THERA FACET CERV OR THOR 2ND L 64491 CPT 360 RC outpatient 1208 966.4 Aetna Commercial PPO 1300 fee schedule 664.4 1300 Case Rate INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC inpatient 1208 604 BCBS Louisiana PPO 604 percent of total billed charges 604 1026.8 50% of Eligible Charges INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC outpatient 1208 966.4 BCBS Louisiana PPO 966.4 percent of total billed charges 664.4 1300 80% of billed charges INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC outpatient 1208 966.4 Cigna Commercial PPO 664.4 percent of total billed charges 664.4 1300 55% of Billed Charges INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC inpatient 1208 604 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 604 1026.8 Inpatient Reimbursement at 85% of Billed Charges INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC outpatient 1208 966.4 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 664.4 1300 Reimbursement at 85% of billed charges INJ DX OR THERA FACET CERV OR THOR 3RD L 64492 CPT 360 RC outpatient 1208 966.4 Aetna Commercial PPO 1300 fee schedule 664.4 1300 Case Rate LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC inpatient 13735.73 6867.87 BCBS Louisiana PPO 6867.87 percent of total billed charges 6867.87 11675.37 50% of Eligible Charges LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC outpatient 13735.73 10988.58 BCBS Louisiana PPO 10988.58 percent of total billed charges 1300 11675.37 80% of billed charges LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC outpatient 13735.73 10988.58 Cigna Commercial PPO 6800 case rate 1300 11675.37 6800 case rate LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC inpatient 13735.73 6867.87 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 6867.87 11675.37 Inpatient Reimbursement at 85% of Billed Charges LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC outpatient 13735.73 10988.58 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 1300 11675.37 Reimbursement at 85% of billed charges LAMINOTOMY W/DECOM OF NERVE ROOT 63042 CPT 360 RC outpatient 13735.73 10988.58 Aetna Commercial PPO 1300 fee schedule 1300 11675.37 Case Rate SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC inpatient 7087.18 3543.59 BCBS Louisiana PPO 3543.59 percent of total billed charges 3543.59 6024.1 50% of Eligible Charges SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC outpatient 7087.18 5669.74 BCBS Louisiana PPO 5669.74 percent of total billed charges 1300 6024.1 80% of billed charges SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC outpatient 7087.18 5669.74 Cigna Commercial PPO 3897.95 percent of total billed charges 1300 6024.1 55% of Billed Charges SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC inpatient 7087.18 3543.59 IMA of Louisiana Commercial PPO 6024.1 percent of total billed charges 3543.59 6024.1 Inpatient Reimbursement at 85% of Billed Charges SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC outpatient 7087.18 5669.74 IMA of Louisiana Commercial PPO 6024.1 percent of total billed charges 1300 6024.1 Reimbursement at 85% of billed charges SUTR DGTAL NRV HD/FT E DGTL NRV 64832 CPT 360 RC outpatient 7087.18 5669.74 Aetna Commercial PPO 1300 fee schedule 1300 6024.1 Case Rate NJX ANES CRV PLEXUS 64413 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges NJX ANES CRV PLEXUS 64413 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1154.68 80% of billed charge NJX ANES CRV PLEXUS 64413 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1154.68 55% of Billed Charges NJX ANES CRV PLEXUS 64413 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges NJX ANES CRV PLEXUS 64413 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1154.68 Reimbursement at 85% of billed charges NJX ANES CRV PLEXUS 64413 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 747.15 percent of total billed charges 747.15 1154.68 55 of billed Charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC inpatient 685.62 342.81 BCBS Louisiana PPO 342.81 percent of total billed charges 342.81 582.78 50% of Eligible Charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC outpatient 685.62 548.5 BCBS Louisiana PPO 548.5 percent of total billed charges 377.09 1300 80% of billed charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC outpatient 685.62 548.5 Cigna Commercial PPO 377.09 percent of total billed charges 377.09 1300 55% of Billed Charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC inpatient 685.62 342.81 IMA of Louisiana Commercial PPO 582.78 percent of total billed charges 342.81 582.78 Inpatient Reimbursement at 85% of Billed Charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC outpatient 685.62 548.5 IMA of Louisiana Commercial PPO 582.78 percent of total billed charges 377.09 1300 Reimbursement at 85% of billed charges DST NROLYTC AGNT PRV FCT ADDL 64634 CPT 360 RC outpatient 685.62 548.5 Aetna Commercial PPO 1300 fee schedule 377.09 1300 Case Rate ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC inpatient 3172.35 1586.18 BCBS Louisiana PPO 1586.18 percent of total billed charges 1586.18 2696.5 50% of Eligible Charges ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC outpatient 3172.35 2537.88 BCBS Louisiana PPO 2537.88 percent of total billed charges 1300 2696.5 80% of billed charges ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC outpatient 3172.35 2537.88 Cigna Commercial PPO 1744.79 percent of total billed charges 1300 2696.5 55% of Billed Charges ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC inpatient 3172.35 1586.18 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1586.18 2696.5 Inpatient Reimbursement at 85% of Billed Charges ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC outpatient 3172.35 2537.88 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1300 2696.5 Reimbursement at 85% of billed charges ARTHRS AID TX SPI&/FX KNE W/FIXJ 29851 CPT 360 RC outpatient 3172.35 2537.88 Aetna Commercial PPO 1300 fee schedule 1300 2696.5 Case Rate DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges DSTRJ NULTYOTH PRPH NRV/BRANCH 64640 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC inpatient 8792.43 4396.22 BCBS Louisiana PPO 4396.22 percent of total billed charges 4396.22 7473.57 50% of Eligible Charges SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC outpatient 8792.43 7033.94 BCBS Louisiana PPO 7033.94 percent of total billed charges 1300 7473.57 80% of billed charges SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC outpatient 8792.43 7033.94 Cigna Commercial PPO 4835.84 percent of total billed charges 1300 7473.57 55% of Billed Charges SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC inpatient 8792.43 4396.22 IMA of Louisiana Commercial PPO 7473.57 percent of total billed charges 4396.22 7473.57 Inpatient Reimbursement at 85% of Billed Charges SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC outpatient 8792.43 7033.94 IMA of Louisiana Commercial PPO 7473.57 percent of total billed charges 1300 7473.57 Reimbursement at 85% of billed charges SUT 1 NV HN/FT CM SENS NV 64834 CPT 360 RC outpatient 8792.43 7033.94 Aetna Commercial PPO 1300 fee schedule 1300 7473.57 Case Rate NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC inpatient 3422.33 1711.17 BCBS Louisiana PPO 1711.17 percent of total billed charges 1711.17 2908.98 50% of Eligible Charges NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC outpatient 3422.33 2737.86 BCBS Louisiana PPO 2737.86 percent of total billed charges 1300 2908.98 80% of billed charges NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC outpatient 3422.33 2737.86 Cigna Commercial PPO 1882.28 percent of total billed charges 1300 2908.98 55% of Billed Charges NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC inpatient 3422.33 1711.17 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1711.17 2908.98 Inpatient Reimbursement at 85% of Billed Charges NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC outpatient 3422.33 2737.86 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1300 2908.98 Reimbursement at 85% of billed charges NEURP DGTAL 1/BTH SM DGT 64702 CPT 360 RC outpatient 3422.33 2737.86 Aetna Commercial PPO 1300 fee schedule 1300 2908.98 Case Rate SPI PNXR LMBR DX 62270 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges SPI PNXR LMBR DX 62270 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges SPI PNXR LMBR DX 62270 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges SPI PNXR LMBR DX 62270 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges SPI PNXR LMBR DX 62270 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges SPI PNXR LMBR DX 62270 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ 63741 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC inpatient 7314.2 3657.1 BCBS Louisiana PPO 3657.1 percent of total billed charges 3657.1 6217.07 50% of Eligible Charges CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC outpatient 7314.2 5851.36 BCBS Louisiana PPO 5851.36 percent of total billed charges 100 6217.07 80% of billed charges CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC outpatient 7314.2 5851.36 Cigna Commercial PPO 4022.81 percent of total billed charges 100 6217.07 55% of Billed Charges CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC inpatient 7314.2 3657.1 IMA of Louisiana Commercial PPO 6217.07 percent of total billed charges 3657.1 6217.07 Inpatient Reimbursement at 85% of Billed Charges CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC outpatient 7314.2 5851.36 IMA of Louisiana Commercial PPO 6217.07 percent of total billed charges 100 6217.07 Reimbursement at 85% of billed charges CRANIOPLASTY SKULL DEFECT TO 5CM 62140 CPT 360 RC outpatient 7314.2 5851.36 Aetna Commercial PPO 100 fee schedule 100 6217.07 Case Rate LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 100 11913.64 55% of Billed Charges LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT 63050 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate PT PARAFFIN BATH 97018 CPT 421 RC inpatient 22.2 11.1 BCBS Louisiana PPO 11.1 percent of total billed charges 11.1 18.87 50% of Eligible Charges PT PARAFFIN BATH 97018 CPT 421 RC outpatient 22.2 17.76 BCBS Louisiana PPO 17.76 percent of total billed charges 17.76 85 80% of billed charge PT PARAFFIN BATH 97018 CPT 421 RC outpatient 22.2 17.76 Cigna Commercial PPO 85 other 17.76 85 63% of Billed Charges PT PARAFFIN BATH 97018 CPT 421 RC inpatient 22.2 11.1 IMA of Louisiana Commercial PPO 18.87 percent of total billed charges 11.1 18.87 Inpatient Reimbursement at 85% of Billed Charges PT PARAFFIN BATH 97018 CPT 421 RC outpatient 22.2 17.76 IMA of Louisiana Commercial PPO 18.87 percent of total billed charges 17.76 85 Reimbursement at 85% of billed charges PT PARAFFIN BATH 97018 CPT 421 RC outpatient 22.2 17.76 Aetna Commercial PPO 20.4 fee schedule 17.76 85 200% Of Aetna Market Fee Schedule ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC inpatient 39.3 19.65 BCBS Louisiana PPO 19.65 percent of total billed charges 19.65 33.41 50% of Eligible Charges ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC outpatient 39.3 31.44 BCBS Louisiana PPO 31.44 percent of total billed charges 31.44 85 80% of billed charge ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC outpatient 39.3 31.44 Cigna Commercial PPO 85 other 31.44 85 63% of Billed Charges ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC inpatient 39.3 19.65 IMA of Louisiana Commercial PPO 33.41 percent of total billed charges 19.65 33.41 Inpatient Reimbursement at 85% of Billed Charges ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC outpatient 39.3 31.44 IMA of Louisiana Commercial PPO 33.41 percent of total billed charges 31.44 85 Reimbursement at 85% of billed charges ELECTRICAL STIMULATION MANUAL 97032 CPT 421 RC outpatient 39.3 31.44 Aetna Commercial PPO 36.54 fee schedule 31.44 85 200% Of Aetna Market Fee Schedule PT MUSCLE TESTING WITH TORGUE CURVES 97752 CPT 421 RC outpatient Cigna Commercial PPO 85 other 85 85 63% of Billed Charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC inpatient 3059.95 1529.98 BCBS Louisiana PPO 1529.98 percent of total billed charges 1529.98 2600.96 50% of Eligible Charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC outpatient 3059.95 2447.96 BCBS Louisiana PPO 2447.96 percent of total billed charges 1300 2600.96 80% of billed charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC outpatient 3059.95 2447.96 Cigna Commercial PPO 1682.97 percent of total billed charges 1300 2600.96 55% of Billed Charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC inpatient 3059.95 1529.98 IMA of Louisiana Commercial PPO 2600.96 percent of total billed charges 1529.98 2600.96 Inpatient Reimbursement at 85% of Billed Charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC outpatient 3059.95 2447.96 IMA of Louisiana Commercial PPO 2600.96 percent of total billed charges 1300 2600.96 Reimbursement at 85% of billed charges EXC NEUROMA M PR NRV XCP SCIATIC 64784 CPT 360 RC outpatient 3059.95 2447.96 Aetna Commercial PPO 1300 fee schedule 1300 2600.96 Case Rate ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC inpatient 2975.88 1487.94 BCBS Louisiana PPO 1487.94 percent of total billed charges 1487.94 2529.5 50% of Eligible Charges ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC outpatient 2975.88 2380.7 BCBS Louisiana PPO 2380.7 percent of total billed charges 1300 2529.5 80% of billed charges ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC outpatient 2975.88 2380.7 Cigna Commercial PPO 1636.73 percent of total billed charges 1300 2529.5 55% of Billed Charges ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC inpatient 2975.88 1487.94 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1487.94 2529.5 Inpatient Reimbursement at 85% of Billed Charges ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC outpatient 2975.88 2380.7 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1300 2529.5 Reimbursement at 85% of billed charges ARTHOSCOPY ELBOW DIAGNOSTIC +- SYNOVIAL 29830 CPT 360 RC outpatient 2975.88 2380.7 Aetna Commercial PPO 1300 fee schedule 1300 2529.5 Case Rate RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC inpatient 1432.13 716.07 BCBS Louisiana PPO 716.07 percent of total billed charges 716.07 1217.31 50% of Eligible Charges RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC outpatient 1432.13 1145.7 BCBS Louisiana PPO 1145.7 percent of total billed charges 787.67 1300 80% of billed charges RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC outpatient 1432.13 1145.7 Cigna Commercial PPO 787.67 percent of total billed charges 787.67 1300 55% of Billed Charges RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC inpatient 1432.13 716.07 IMA of Louisiana Commercial PPO 1217.31 percent of total billed charges 716.07 1217.31 Inpatient Reimbursement at 85% of Billed Charges RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC outpatient 1432.13 1145.7 IMA of Louisiana Commercial PPO 1217.31 percent of total billed charges 787.67 1300 Reimbursement at 85% of billed charges RPR BLOOD VESSEL DIRECT LOWER EXTREMITY 35226 CPT 360 RC outpatient 1432.13 1145.7 Aetna Commercial PPO 1300 fee schedule 787.67 1300 Case Rate WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 1300 11913.64 55% of Billed Charges WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges WRIST ARTHROSCOPY/SURGERY 29847 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC inpatient 2457.43 1228.72 BCBS Louisiana PPO 1228.72 percent of total billed charges 1228.72 2088.82 50% of Eligible Charges "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC outpatient 2457.43 1965.94 BCBS Louisiana PPO 1965.94 percent of total billed charges 1300 2088.82 80% of billed charges "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC outpatient 2457.43 1965.94 Cigna Commercial PPO 1351.59 percent of total billed charges 1300 2088.82 55% of Billed Charges "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC inpatient 2457.43 1228.72 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1228.72 2088.82 Inpatient Reimbursement at 85% of Billed Charges "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC outpatient 2457.43 1965.94 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1300 2088.82 Reimbursement at 85% of billed charges "REPLACEMENT, CMPLT, OF PICC DEVICE" 36584 CPT 360 RC outpatient 2457.43 1965.94 Aetna Commercial PPO 1300 fee schedule 1300 2088.82 Case Rate JOINT CAMP PREHAB 97113 CPT 421 RC inpatient 25 12.5 BCBS Louisiana PPO 12.5 percent of total billed charges 12.5 21.25 50% of Eligible Charges JOINT CAMP PREHAB 97113 CPT 421 RC outpatient 25 20 BCBS Louisiana PPO 20 percent of total billed charges 20 85 80% of billed charge JOINT CAMP PREHAB 97113 CPT 421 RC outpatient 25 20 Cigna Commercial PPO 85 other 20 85 63% of Billed Charges JOINT CAMP PREHAB 97113 CPT 421 RC inpatient 25 12.5 IMA of Louisiana Commercial PPO 21.25 percent of total billed charges 12.5 21.25 Inpatient Reimbursement at 85% of Billed Charges JOINT CAMP PREHAB 97113 CPT 421 RC outpatient 25 20 IMA of Louisiana Commercial PPO 21.25 percent of total billed charges 20 85 Reimbursement at 85% of billed charges JOINT CAMP PREHAB 97113 CPT 421 RC outpatient 25 20 Aetna Commercial PPO 80.64 fee schedule 20 85 200% Of Aetna Market Fee Schedule XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges ULTRASOUND RENAL - COMPLETE 76770 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition VENOGRAM 75820 CPT 320 RC inpatient 1531.43 765.72 BCBS Louisiana PPO 765.72 percent of total billed charges 765.72 1301.72 50% of Eligible Charges VENOGRAM 75820 CPT 320 RC outpatient 1531.43 1072 BCBS Louisiana PPO 1072 percent of total billed charges 700 1301.72 70% of billed charges VENOGRAM 75820 CPT 320 RC outpatient 1531.43 1072 Cigna Commercial PPO 842.29 percent of total billed charges 700 1301.72 55% of Billed Charges VENOGRAM 75820 CPT 320 RC inpatient 1531.43 765.72 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 765.72 1301.72 Inpatient Reimbursement at 85% of Billed Charges VENOGRAM 75820 CPT 320 RC outpatient 1531.43 1072 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 700 1301.72 Reimbursement at 85% of billed charges VENOGRAM 75820 CPT 320 RC outpatient 1531.43 1072 Aetna Commercial PPO 700 case rate 700 1301.72 700 Per Code Per DOS Paid In Addition PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC inpatient 72.73 36.37 BCBS Louisiana PPO 36.37 percent of total billed charges 36.37 61.82 50% of Eligible Charges PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC outpatient 72.73 58.18 BCBS Louisiana PPO 58.18 percent of total billed charges 49.34 85 80% of billed charge PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC outpatient 72.73 58.18 Cigna Commercial PPO 85 other 49.34 85 63% of Billed Charges PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC inpatient 72.73 36.37 IMA of Louisiana Commercial PPO 61.82 percent of total billed charges 36.37 61.82 Inpatient Reimbursement at 85% of Billed Charges PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC outpatient 72.73 58.18 IMA of Louisiana Commercial PPO 61.82 percent of total billed charges 49.34 85 Reimbursement at 85% of billed charges PT IONTOPHORESIS EA 15 MINUTES 97033 CPT 421 RC outpatient 72.73 58.18 Aetna Commercial PPO 49.34 fee schedule 49.34 85 200% Of Aetna Market Fee Schedule PT PT 15 MIN GAIT MIN 97116 CPT 421 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges PT PT 15 MIN GAIT MIN 97116 CPT 421 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 54.28 148.75 80% of billed charge PT PT 15 MIN GAIT MIN 97116 CPT 421 RC outpatient 175 140 Cigna Commercial PPO 85 other 54.28 148.75 63% of Billed Charges PT PT 15 MIN GAIT MIN 97116 CPT 421 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges PT PT 15 MIN GAIT MIN 97116 CPT 421 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 54.28 148.75 Reimbursement at 85% of billed charges PT PT 15 MIN GAIT MIN 97116 CPT 421 RC outpatient 175 140 Aetna Commercial PPO 54.28 fee schedule 54.28 148.75 200% Of Aetna Market Fee Schedule PT PT RE-EVALUATION 97002 CPT 424 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges PT PT RE-EVALUATION 97002 CPT 424 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 85 148.75 80% of billed charge PT PT RE-EVALUATION 97002 CPT 424 RC outpatient 175 140 Cigna Commercial PPO 85 other 85 148.75 63% of Billed Charges PT PT RE-EVALUATION 97002 CPT 424 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges PT PT RE-EVALUATION 97002 CPT 424 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 85 148.75 Reimbursement at 85% of billed charges PT PT RE-EVALUATION 97002 CPT 424 RC outpatient 175 140 Aetna Commercial PPO 96.25 percent of total billed charges 85 148.75 55 of billed Charges PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC inpatient 86.35 43.18 BCBS Louisiana PPO 43.18 percent of total billed charges 43.18 73.4 50% of Eligible Charges PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC outpatient 86.35 69.08 BCBS Louisiana PPO 69.08 percent of total billed charges 55.88 85 80% of billed charge PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC outpatient 86.35 69.08 Cigna Commercial PPO 85 other 55.88 85 63% of Billed Charges PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC inpatient 86.35 43.18 IMA of Louisiana Commercial PPO 73.4 percent of total billed charges 43.18 73.4 Inpatient Reimbursement at 85% of Billed Charges PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC outpatient 86.35 69.08 IMA of Louisiana Commercial PPO 73.4 percent of total billed charges 55.88 85 Reimbursement at 85% of billed charges PT SENSORY INTEGRATIVE TECHNIQUES 97533 CPT 421 RC outpatient 86.35 69.08 Aetna Commercial PPO 55.88 fee schedule 55.88 85 200% Of Aetna Market Fee Schedule INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges INJECT ANES LUBAR PLEXUS POST ONT NFS CA 64449 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC inpatient 10.52 5.26 BCBS Louisiana PPO 5.26 percent of total billed charges 5.26 8.94 50% of Eligible Charges ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC outpatient 10.52 7.36 BCBS Louisiana PPO 7.36 percent of total billed charges 5.79 8.94 70% of billed charges ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC outpatient 10.52 7.36 Cigna Commercial PPO 5.79 percent of total billed charges 5.79 8.94 55% of Billed Charges ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC inpatient 10.52 5.26 IMA of Louisiana Commercial PPO 8.94 percent of total billed charges 5.26 8.94 Inpatient Reimbursement at 85% of Billed Charges ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC outpatient 10.52 7.36 IMA of Louisiana Commercial PPO 8.94 percent of total billed charges 5.79 8.94 Reimbursement at 85% of billed charges ..TESTING ONLY PATHOLOGY 85007 CPT 384 RC outpatient 10.52 7.36 Aetna Commercial PPO 8.18 fee schedule 5.79 8.94 200% Of Aetna Market Fee Schedule Hospital Technical Rate BLUE X 5 99070 CPT 271 RC "GP,59" inpatient 67.08 33.54 BCBS Louisiana PPO 33.54 percent of total billed charges 33.54 57.02 50% of Eligible Charges BLUE X 5 99070 CPT 271 RC "GP,59" outpatient 67.08 53.66 BCBS Louisiana PPO 53.66 percent of total billed charges 36.89 57.02 80% of billed charge BLUE X 5 99070 CPT 271 RC "GP,59" outpatient 67.08 53.66 Cigna Commercial PPO 36.89 percent of total billed charges 36.89 57.02 55% of Billed Charges BLUE X 5 99070 CPT 271 RC "GP,59" inpatient 67.08 33.54 IMA of Louisiana Commercial PPO 57.02 percent of total billed charges 33.54 57.02 Inpatient Reimbursement at 85% of Billed Charges BLUE X 5 99070 CPT 271 RC "GP,59" outpatient 67.08 53.66 IMA of Louisiana Commercial PPO 57.02 percent of total billed charges 36.89 57.02 Reimbursement at 85% of billed charges BLUE X 5 99070 CPT 271 RC "GP,59" outpatient 67.08 53.66 Aetna Commercial PPO 36.89 percent of total billed charges 36.89 57.02 55 of billed Charges ACE ELAST 2 (NON-STERILE) 270 RC inpatient 1.27 0.64 BCBS Louisiana PPO 0.64 percent of total billed charges 0.64 1.08 50% of Eligible Charges ACE ELAST 2 (NON-STERILE) 270 RC outpatient 1.27 1.02 BCBS Louisiana PPO 1.02 percent of total billed charges 0.7 1.08 80% of billed charge ACE ELAST 2 (NON-STERILE) 270 RC outpatient 1.27 1.02 Cigna Commercial PPO 0.7 percent of total billed charges 0.7 1.08 55% of Billed Charges ACE ELAST 2 (NON-STERILE) 270 RC inpatient 1.27 0.64 IMA of Louisiana Commercial PPO 1.08 percent of total billed charges 0.64 1.08 Inpatient Reimbursement at 85% of Billed Charges ACE ELAST 2 (NON-STERILE) 270 RC outpatient 1.27 1.02 IMA of Louisiana Commercial PPO 1.08 percent of total billed charges 0.7 1.08 Reimbursement at 85% of billed charges ACE ELAST 2 (NON-STERILE) 270 RC outpatient 1.27 1.02 Aetna Commercial PPO 0.7 percent of total billed charges 0.7 1.08 55 of billed Charges COTTON FORM 4 272 RC inpatient 15.36 7.68 BCBS Louisiana PPO 7.68 percent of total billed charges 7.68 13.06 50% of Eligible Charges COTTON FORM 4 272 RC outpatient 15.36 12.29 BCBS Louisiana PPO 12.29 percent of total billed charges 8.45 13.06 80% of billed charge COTTON FORM 4 272 RC outpatient 15.36 12.29 Cigna Commercial PPO 8.45 percent of total billed charges 8.45 13.06 55% of Billed Charges COTTON FORM 4 272 RC inpatient 15.36 7.68 IMA of Louisiana Commercial PPO 13.06 percent of total billed charges 7.68 13.06 Inpatient Reimbursement at 85% of Billed Charges COTTON FORM 4 272 RC outpatient 15.36 12.29 IMA of Louisiana Commercial PPO 13.06 percent of total billed charges 8.45 13.06 Reimbursement at 85% of billed charges COTTON FORM 4 272 RC outpatient 15.36 12.29 Aetna Commercial PPO 8.45 percent of total billed charges 8.45 13.06 55 of billed Charges BUR B-1 #F2/8TA23 272 RC inpatient 227.5 113.75 BCBS Louisiana PPO 113.75 percent of total billed charges 113.75 193.38 50% of Eligible Charges BUR B-1 #F2/8TA23 272 RC outpatient 227.5 182 BCBS Louisiana PPO 182 percent of total billed charges 125.13 193.38 80% of billed charge BUR B-1 #F2/8TA23 272 RC outpatient 227.5 182 Cigna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55% of Billed Charges BUR B-1 #F2/8TA23 272 RC inpatient 227.5 113.75 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 113.75 193.38 Inpatient Reimbursement at 85% of Billed Charges BUR B-1 #F2/8TA23 272 RC outpatient 227.5 182 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 125.13 193.38 Reimbursement at 85% of billed charges BUR B-1 #F2/8TA23 272 RC outpatient 227.5 182 Aetna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55 of billed Charges BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 506.25 253.13 BCBS Louisiana PPO 253.13 percent of total billed charges 253.13 430.31 50% of Eligible Charges BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 506.25 405 BCBS Louisiana PPO 405 percent of total billed charges 187.31 430.31 80% of billed charge BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 506.25 405 Cigna Commercial PPO 293.63 percent of total billed charges 187.31 430.31 58% of Billed Charges/$500 Threshold BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 506.25 253.13 IMA of Louisiana Commercial PPO 430.31 percent of total billed charges 253.13 430.31 Inpatient Reimbursement at 85% of Billed Charges BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 506.25 405 IMA of Louisiana Commercial PPO 430.31 percent of total billed charges 187.31 430.31 Reimbursement at 85% of billed charges BONE 15CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 506.25 405 Aetna Commercial PPO 187.31 percent of total billed charges 187.31 430.31 37% Of Billed Charges 2000 BUR 5.0MM ROUND 45MM -SYN 272 RC inpatient 332.29 166.15 BCBS Louisiana PPO 166.15 percent of total billed charges 166.15 282.45 50% of Eligible Charges BUR 5.0MM ROUND 45MM -SYN 272 RC outpatient 332.29 265.83 BCBS Louisiana PPO 265.83 percent of total billed charges 182.76 282.45 80% of billed charge BUR 5.0MM ROUND 45MM -SYN 272 RC outpatient 332.29 265.83 Cigna Commercial PPO 182.76 percent of total billed charges 182.76 282.45 55% of Billed Charges BUR 5.0MM ROUND 45MM -SYN 272 RC inpatient 332.29 166.15 IMA of Louisiana Commercial PPO 282.45 percent of total billed charges 166.15 282.45 Inpatient Reimbursement at 85% of Billed Charges BUR 5.0MM ROUND 45MM -SYN 272 RC outpatient 332.29 265.83 IMA of Louisiana Commercial PPO 282.45 percent of total billed charges 182.76 282.45 Reimbursement at 85% of billed charges BUR 5.0MM ROUND 45MM -SYN 272 RC outpatient 332.29 265.83 Aetna Commercial PPO 182.76 percent of total billed charges 182.76 282.45 55 of billed Charges CAST PADDING 2 270 RC inpatient 191.77 95.89 BCBS Louisiana PPO 95.89 percent of total billed charges 95.89 163 50% of Eligible Charges CAST PADDING 2 270 RC outpatient 191.77 153.42 BCBS Louisiana PPO 153.42 percent of total billed charges 105.47 163 80% of billed charge CAST PADDING 2 270 RC outpatient 191.77 153.42 Cigna Commercial PPO 105.47 percent of total billed charges 105.47 163 55% of Billed Charges CAST PADDING 2 270 RC inpatient 191.77 95.89 IMA of Louisiana Commercial PPO 163 percent of total billed charges 95.89 163 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 2 270 RC outpatient 191.77 153.42 IMA of Louisiana Commercial PPO 163 percent of total billed charges 105.47 163 Reimbursement at 85% of billed charges CAST PADDING 2 270 RC outpatient 191.77 153.42 Aetna Commercial PPO 105.47 percent of total billed charges 105.47 163 55 of billed Charges CAST PADDING 3 270 RC inpatient 58.16 29.08 BCBS Louisiana PPO 29.08 percent of total billed charges 29.08 49.44 50% of Eligible Charges CAST PADDING 3 270 RC outpatient 58.16 46.53 BCBS Louisiana PPO 46.53 percent of total billed charges 31.99 49.44 80% of billed charge CAST PADDING 3 270 RC outpatient 58.16 46.53 Cigna Commercial PPO 31.99 percent of total billed charges 31.99 49.44 55% of Billed Charges CAST PADDING 3 270 RC inpatient 58.16 29.08 IMA of Louisiana Commercial PPO 49.44 percent of total billed charges 29.08 49.44 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 3 270 RC outpatient 58.16 46.53 IMA of Louisiana Commercial PPO 49.44 percent of total billed charges 31.99 49.44 Reimbursement at 85% of billed charges CAST PADDING 3 270 RC outpatient 58.16 46.53 Aetna Commercial PPO 31.99 percent of total billed charges 31.99 49.44 55 of billed Charges COTTONOIDS 1/2 X 1/2 272 RC inpatient 25.92 12.96 BCBS Louisiana PPO 12.96 percent of total billed charges 12.96 22.03 50% of Eligible Charges COTTONOIDS 1/2 X 1/2 272 RC outpatient 25.92 20.74 BCBS Louisiana PPO 20.74 percent of total billed charges 14.26 22.03 80% of billed charge COTTONOIDS 1/2 X 1/2 272 RC outpatient 25.92 20.74 Cigna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55% of Billed Charges COTTONOIDS 1/2 X 1/2 272 RC inpatient 25.92 12.96 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 12.96 22.03 Inpatient Reimbursement at 85% of Billed Charges COTTONOIDS 1/2 X 1/2 272 RC outpatient 25.92 20.74 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 14.26 22.03 Reimbursement at 85% of billed charges COTTONOIDS 1/2 X 1/2 272 RC outpatient 25.92 20.74 Aetna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55 of billed Charges CRUTCH ALUM DRESSED TL ADULT 270 RC inpatient 89.36 44.68 BCBS Louisiana PPO 44.68 percent of total billed charges 44.68 75.96 50% of Eligible Charges CRUTCH ALUM DRESSED TL ADULT 270 RC outpatient 89.36 71.49 BCBS Louisiana PPO 71.49 percent of total billed charges 49.15 75.96 80% of billed charge CRUTCH ALUM DRESSED TL ADULT 270 RC outpatient 89.36 71.49 Cigna Commercial PPO 49.15 percent of total billed charges 49.15 75.96 55% of Billed Charges CRUTCH ALUM DRESSED TL ADULT 270 RC inpatient 89.36 44.68 IMA of Louisiana Commercial PPO 75.96 percent of total billed charges 44.68 75.96 Inpatient Reimbursement at 85% of Billed Charges CRUTCH ALUM DRESSED TL ADULT 270 RC outpatient 89.36 71.49 IMA of Louisiana Commercial PPO 75.96 percent of total billed charges 49.15 75.96 Reimbursement at 85% of billed charges CRUTCH ALUM DRESSED TL ADULT 270 RC outpatient 89.36 71.49 Aetna Commercial PPO 49.15 percent of total billed charges 49.15 75.96 55 of billed Charges DRAPE PREP ROLL (NS CLEAR) 270 RC inpatient 750 375 BCBS Louisiana PPO 375 percent of total billed charges 375 637.5 50% of Eligible Charges DRAPE PREP ROLL (NS CLEAR) 270 RC outpatient 750 600 BCBS Louisiana PPO 600 percent of total billed charges 412.5 637.5 80% of billed charge DRAPE PREP ROLL (NS CLEAR) 270 RC outpatient 750 600 Cigna Commercial PPO 412.5 percent of total billed charges 412.5 637.5 55% of Billed Charges DRAPE PREP ROLL (NS CLEAR) 270 RC inpatient 750 375 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 375 637.5 Inpatient Reimbursement at 85% of Billed Charges DRAPE PREP ROLL (NS CLEAR) 270 RC outpatient 750 600 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 412.5 637.5 Reimbursement at 85% of billed charges DRAPE PREP ROLL (NS CLEAR) 270 RC outpatient 750 600 Aetna Commercial PPO 412.5 percent of total billed charges 412.5 637.5 55 of billed Charges ENDO TUBE W/CUFF 4.5 272 RC inpatient 111.93 55.97 BCBS Louisiana PPO 55.97 percent of total billed charges 55.97 95.14 50% of Eligible Charges ENDO TUBE W/CUFF 4.5 272 RC outpatient 111.93 89.54 BCBS Louisiana PPO 89.54 percent of total billed charges 61.56 95.14 80% of billed charge ENDO TUBE W/CUFF 4.5 272 RC outpatient 111.93 89.54 Cigna Commercial PPO 61.56 percent of total billed charges 61.56 95.14 55% of Billed Charges ENDO TUBE W/CUFF 4.5 272 RC inpatient 111.93 55.97 IMA of Louisiana Commercial PPO 95.14 percent of total billed charges 55.97 95.14 Inpatient Reimbursement at 85% of Billed Charges ENDO TUBE W/CUFF 4.5 272 RC outpatient 111.93 89.54 IMA of Louisiana Commercial PPO 95.14 percent of total billed charges 61.56 95.14 Reimbursement at 85% of billed charges ENDO TUBE W/CUFF 4.5 272 RC outpatient 111.93 89.54 Aetna Commercial PPO 61.56 percent of total billed charges 61.56 95.14 55 of billed Charges EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC inpatient 530.43 265.22 BCBS Louisiana PPO 265.22 percent of total billed charges 265.22 450.87 50% of Eligible Charges EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC outpatient 530.43 424.34 BCBS Louisiana PPO 424.34 percent of total billed charges 291.74 450.87 80% of billed charge EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC outpatient 530.43 424.34 Cigna Commercial PPO 291.74 percent of total billed charges 291.74 450.87 55% of Billed Charges EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC inpatient 530.43 265.22 IMA of Louisiana Commercial PPO 450.87 percent of total billed charges 265.22 450.87 Inpatient Reimbursement at 85% of Billed Charges EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC outpatient 530.43 424.34 IMA of Louisiana Commercial PPO 450.87 percent of total billed charges 291.74 450.87 Reimbursement at 85% of billed charges EPIDURAL TRAY (PAIN MANAGEMENT) 272 RC outpatient 530.43 424.34 Aetna Commercial PPO 291.74 percent of total billed charges 291.74 450.87 55 of billed Charges GLOVE ORTHO 7.5 272 RC inpatient 4.93 2.47 BCBS Louisiana PPO 2.47 percent of total billed charges 2.47 4.19 50% of Eligible Charges GLOVE ORTHO 7.5 272 RC outpatient 4.93 3.94 BCBS Louisiana PPO 3.94 percent of total billed charges 2.71 4.19 80% of billed charge GLOVE ORTHO 7.5 272 RC outpatient 4.93 3.94 Cigna Commercial PPO 2.71 percent of total billed charges 2.71 4.19 55% of Billed Charges GLOVE ORTHO 7.5 272 RC inpatient 4.93 2.47 IMA of Louisiana Commercial PPO 4.19 percent of total billed charges 2.47 4.19 Inpatient Reimbursement at 85% of Billed Charges GLOVE ORTHO 7.5 272 RC outpatient 4.93 3.94 IMA of Louisiana Commercial PPO 4.19 percent of total billed charges 2.71 4.19 Reimbursement at 85% of billed charges GLOVE ORTHO 7.5 272 RC outpatient 4.93 3.94 Aetna Commercial PPO 2.71 percent of total billed charges 2.71 4.19 55 of billed Charges GLOVE STERILE 7.5 LTX 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges GLOVE STERILE 7.5 LTX 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge GLOVE STERILE 7.5 LTX 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges GLOVE STERILE 7.5 LTX 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 7.5 LTX 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges GLOVE STERILE 7.5 LTX 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges GLOVE STERILE 9.0 272 RC inpatient 208.57 104.29 BCBS Louisiana PPO 104.29 percent of total billed charges 104.29 177.28 50% of Eligible Charges GLOVE STERILE 9.0 272 RC outpatient 208.57 166.86 BCBS Louisiana PPO 166.86 percent of total billed charges 114.71 177.28 80% of billed charge GLOVE STERILE 9.0 272 RC outpatient 208.57 166.86 Cigna Commercial PPO 114.71 percent of total billed charges 114.71 177.28 55% of Billed Charges GLOVE STERILE 9.0 272 RC inpatient 208.57 104.29 IMA of Louisiana Commercial PPO 177.28 percent of total billed charges 104.29 177.28 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 9.0 272 RC outpatient 208.57 166.86 IMA of Louisiana Commercial PPO 177.28 percent of total billed charges 114.71 177.28 Reimbursement at 85% of billed charges GLOVE STERILE 9.0 272 RC outpatient 208.57 166.86 Aetna Commercial PPO 114.71 percent of total billed charges 114.71 177.28 55 of billed Charges ICE PACK - LARGE 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges ICE PACK - LARGE 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge ICE PACK - LARGE 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges ICE PACK - LARGE 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges ICE PACK - LARGE 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges ICE PACK - LARGE 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC inpatient 404 202 BCBS Louisiana PPO 202 percent of total billed charges 202 343.4 50% of Eligible Charges IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC outpatient 404 323.2 BCBS Louisiana PPO 323.2 percent of total billed charges 222.2 343.4 80% of billed charge IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC outpatient 404 323.2 Cigna Commercial PPO 222.2 percent of total billed charges 222.2 343.4 55% of Billed Charges IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC inpatient 404 202 IMA of Louisiana Commercial PPO 343.4 percent of total billed charges 202 343.4 Inpatient Reimbursement at 85% of Billed Charges IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC outpatient 404 323.2 IMA of Louisiana Commercial PPO 343.4 percent of total billed charges 222.2 343.4 Reimbursement at 85% of billed charges IV MICROBORE EXT SET 12 - DISCO TUBING 272 RC outpatient 404 323.2 Aetna Commercial PPO 222.2 percent of total billed charges 222.2 343.4 55 of billed Charges K-WIRE THREADED .045 272 RC inpatient 460.25 230.13 BCBS Louisiana PPO 230.13 percent of total billed charges 230.13 391.21 50% of Eligible Charges K-WIRE THREADED .045 272 RC outpatient 460.25 368.2 BCBS Louisiana PPO 368.2 percent of total billed charges 253.14 391.21 80% of billed charge K-WIRE THREADED .045 272 RC outpatient 460.25 368.2 Cigna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55% of Billed Charges K-WIRE THREADED .045 272 RC inpatient 460.25 230.13 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 230.13 391.21 Inpatient Reimbursement at 85% of Billed Charges K-WIRE THREADED .045 272 RC outpatient 460.25 368.2 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 253.14 391.21 Reimbursement at 85% of billed charges K-WIRE THREADED .045 272 RC outpatient 460.25 368.2 Aetna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55 of billed Charges K-WIRE THREADED .054 272 RC inpatient 460.25 230.13 BCBS Louisiana PPO 230.13 percent of total billed charges 230.13 391.21 50% of Eligible Charges K-WIRE THREADED .054 272 RC outpatient 460.25 368.2 BCBS Louisiana PPO 368.2 percent of total billed charges 253.14 391.21 80% of billed charge K-WIRE THREADED .054 272 RC outpatient 460.25 368.2 Cigna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55% of Billed Charges K-WIRE THREADED .054 272 RC inpatient 460.25 230.13 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 230.13 391.21 Inpatient Reimbursement at 85% of Billed Charges K-WIRE THREADED .054 272 RC outpatient 460.25 368.2 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 253.14 391.21 Reimbursement at 85% of billed charges K-WIRE THREADED .054 272 RC outpatient 460.25 368.2 Aetna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55 of billed Charges PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 385.25 192.63 BCBS Louisiana PPO 192.63 percent of total billed charges 192.63 327.46 50% of Eligible Charges PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 385.25 308.2 BCBS Louisiana PPO 308.2 percent of total billed charges 142.54 327.46 80% of billed charge PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 385.25 308.2 Cigna Commercial PPO 223.45 percent of total billed charges 142.54 327.46 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 385.25 192.63 IMA of Louisiana Commercial PPO 327.46 percent of total billed charges 192.63 327.46 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 385.25 308.2 IMA of Louisiana Commercial PPO 327.46 percent of total billed charges 142.54 327.46 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR LCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 385.25 308.2 Aetna Commercial PPO 142.54 percent of total billed charges 142.54 327.46 37% Of Billed Charges 2000 NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC inpatient 45.12 22.56 BCBS Louisiana PPO 22.56 percent of total billed charges 22.56 38.35 50% of Eligible Charges NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC outpatient 45.12 36.1 BCBS Louisiana PPO 36.1 percent of total billed charges 24.82 38.35 80% of billed charge NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC outpatient 45.12 36.1 Cigna Commercial PPO 24.82 percent of total billed charges 24.82 38.35 55% of Billed Charges NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC inpatient 45.12 22.56 IMA of Louisiana Commercial PPO 38.35 percent of total billed charges 22.56 38.35 Inpatient Reimbursement at 85% of Billed Charges NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC outpatient 45.12 36.1 IMA of Louisiana Commercial PPO 38.35 percent of total billed charges 24.82 38.35 Reimbursement at 85% of billed charges NEEDLE TUOHY EPIDURAL 20G X 3 1/2 272 RC outpatient 45.12 36.1 Aetna Commercial PPO 24.82 percent of total billed charges 24.82 38.35 55 of billed Charges NEEDLE TUOHY EPIDURAL 20G X 6 272 RC inpatient 640.63 320.32 BCBS Louisiana PPO 320.32 percent of total billed charges 320.32 544.54 50% of Eligible Charges NEEDLE TUOHY EPIDURAL 20G X 6 272 RC outpatient 640.63 512.5 BCBS Louisiana PPO 512.5 percent of total billed charges 352.35 544.54 80% of billed charge NEEDLE TUOHY EPIDURAL 20G X 6 272 RC outpatient 640.63 512.5 Cigna Commercial PPO 352.35 percent of total billed charges 352.35 544.54 55% of Billed Charges NEEDLE TUOHY EPIDURAL 20G X 6 272 RC inpatient 640.63 320.32 IMA of Louisiana Commercial PPO 544.54 percent of total billed charges 320.32 544.54 Inpatient Reimbursement at 85% of Billed Charges NEEDLE TUOHY EPIDURAL 20G X 6 272 RC outpatient 640.63 512.5 IMA of Louisiana Commercial PPO 544.54 percent of total billed charges 352.35 544.54 Reimbursement at 85% of billed charges NEEDLE TUOHY EPIDURAL 20G X 6 272 RC outpatient 640.63 512.5 Aetna Commercial PPO 352.35 percent of total billed charges 352.35 544.54 55 of billed Charges ORTHO MINOR PACK - PHS 272 RC inpatient 486.98 243.49 BCBS Louisiana PPO 243.49 percent of total billed charges 243.49 413.93 50% of Eligible Charges ORTHO MINOR PACK - PHS 272 RC outpatient 486.98 389.58 BCBS Louisiana PPO 389.58 percent of total billed charges 267.84 413.93 80% of billed charge ORTHO MINOR PACK - PHS 272 RC outpatient 486.98 389.58 Cigna Commercial PPO 267.84 percent of total billed charges 267.84 413.93 55% of Billed Charges ORTHO MINOR PACK - PHS 272 RC inpatient 486.98 243.49 IMA of Louisiana Commercial PPO 413.93 percent of total billed charges 243.49 413.93 Inpatient Reimbursement at 85% of Billed Charges ORTHO MINOR PACK - PHS 272 RC outpatient 486.98 389.58 IMA of Louisiana Commercial PPO 413.93 percent of total billed charges 267.84 413.93 Reimbursement at 85% of billed charges ORTHO MINOR PACK - PHS 272 RC outpatient 486.98 389.58 Aetna Commercial PPO 267.84 percent of total billed charges 267.84 413.93 55 of billed Charges CLEANSER SKIN PERI 2-N-1 270 RC inpatient 344.4 172.2 BCBS Louisiana PPO 172.2 percent of total billed charges 172.2 292.74 50% of Eligible Charges CLEANSER SKIN PERI 2-N-1 270 RC outpatient 344.4 275.52 BCBS Louisiana PPO 275.52 percent of total billed charges 189.42 292.74 80% of billed charge CLEANSER SKIN PERI 2-N-1 270 RC outpatient 344.4 275.52 Cigna Commercial PPO 189.42 percent of total billed charges 189.42 292.74 55% of Billed Charges CLEANSER SKIN PERI 2-N-1 270 RC inpatient 344.4 172.2 IMA of Louisiana Commercial PPO 292.74 percent of total billed charges 172.2 292.74 Inpatient Reimbursement at 85% of Billed Charges CLEANSER SKIN PERI 2-N-1 270 RC outpatient 344.4 275.52 IMA of Louisiana Commercial PPO 292.74 percent of total billed charges 189.42 292.74 Reimbursement at 85% of billed charges CLEANSER SKIN PERI 2-N-1 270 RC outpatient 344.4 275.52 Aetna Commercial PPO 189.42 percent of total billed charges 189.42 292.74 55 of billed Charges PIN BALL .062 270 RC inpatient 161 80.5 BCBS Louisiana PPO 80.5 percent of total billed charges 80.5 136.85 50% of Eligible Charges PIN BALL .062 270 RC outpatient 161 128.8 BCBS Louisiana PPO 128.8 percent of total billed charges 88.55 136.85 80% of billed charge PIN BALL .062 270 RC outpatient 161 128.8 Cigna Commercial PPO 88.55 percent of total billed charges 88.55 136.85 55% of Billed Charges PIN BALL .062 270 RC inpatient 161 80.5 IMA of Louisiana Commercial PPO 136.85 percent of total billed charges 80.5 136.85 Inpatient Reimbursement at 85% of Billed Charges PIN BALL .062 270 RC outpatient 161 128.8 IMA of Louisiana Commercial PPO 136.85 percent of total billed charges 88.55 136.85 Reimbursement at 85% of billed charges PIN BALL .062 270 RC outpatient 161 128.8 Aetna Commercial PPO 88.55 percent of total billed charges 88.55 136.85 55 of billed Charges PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC inpatient 203.25 101.63 BCBS Louisiana PPO 101.63 percent of total billed charges 101.63 172.76 50% of Eligible Charges PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 BCBS Louisiana PPO 162.6 percent of total billed charges 75.2 172.76 80% of billed charge PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 Cigna Commercial PPO 117.89 percent of total billed charges 75.2 172.76 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC inpatient 203.25 101.63 IMA of Louisiana Commercial PPO 172.76 percent of total billed charges 101.63 172.76 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 IMA of Louisiana Commercial PPO 172.76 percent of total billed charges 75.2 172.76 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR W/ 5 HOLE 61MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 Aetna Commercial PPO 75.2 percent of total billed charges 75.2 172.76 37% Of Billed Charges 2000 PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 64.75 148.75 80% of billed charge PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC outpatient 175 140 Cigna Commercial PPO 101.5 percent of total billed charges 64.75 148.75 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 64.75 148.75 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR W/ 6 HOLE 73MM - SYN C1713 HCPCS 278 RC outpatient 175 140 Aetna Commercial PPO 64.75 percent of total billed charges 64.75 148.75 37% Of Billed Charges 2000 POLARCARE CUBE W/ PAD 270 RC inpatient 315 157.5 BCBS Louisiana PPO 157.5 percent of total billed charges 157.5 267.75 50% of Eligible Charges POLARCARE CUBE W/ PAD 270 RC outpatient 315 252 BCBS Louisiana PPO 252 percent of total billed charges 173.25 267.75 80% of billed charge POLARCARE CUBE W/ PAD 270 RC outpatient 315 252 Cigna Commercial PPO 173.25 percent of total billed charges 173.25 267.75 55% of Billed Charges POLARCARE CUBE W/ PAD 270 RC inpatient 315 157.5 IMA of Louisiana Commercial PPO 267.75 percent of total billed charges 157.5 267.75 Inpatient Reimbursement at 85% of Billed Charges POLARCARE CUBE W/ PAD 270 RC outpatient 315 252 IMA of Louisiana Commercial PPO 267.75 percent of total billed charges 173.25 267.75 Reimbursement at 85% of billed charges POLARCARE CUBE W/ PAD 270 RC outpatient 315 252 Aetna Commercial PPO 173.25 percent of total billed charges 173.25 267.75 55 of billed Charges GUPPY PUDDLE FLOOR ASPIRATOR 270 RC inpatient 674.77 337.39 BCBS Louisiana PPO 337.39 percent of total billed charges 337.39 573.55 50% of Eligible Charges GUPPY PUDDLE FLOOR ASPIRATOR 270 RC outpatient 674.77 539.82 BCBS Louisiana PPO 539.82 percent of total billed charges 371.12 573.55 80% of billed charge GUPPY PUDDLE FLOOR ASPIRATOR 270 RC outpatient 674.77 539.82 Cigna Commercial PPO 371.12 percent of total billed charges 371.12 573.55 55% of Billed Charges GUPPY PUDDLE FLOOR ASPIRATOR 270 RC inpatient 674.77 337.39 IMA of Louisiana Commercial PPO 573.55 percent of total billed charges 337.39 573.55 Inpatient Reimbursement at 85% of Billed Charges GUPPY PUDDLE FLOOR ASPIRATOR 270 RC outpatient 674.77 539.82 IMA of Louisiana Commercial PPO 573.55 percent of total billed charges 371.12 573.55 Reimbursement at 85% of billed charges GUPPY PUDDLE FLOOR ASPIRATOR 270 RC outpatient 674.77 539.82 Aetna Commercial PPO 371.12 percent of total billed charges 371.12 573.55 55 of billed Charges OBSERVATION EA ADD HR G0378 HCPCS 762 RC inpatient 43.4 21.7 BCBS Louisiana PPO 21.7 percent of total billed charges 21.7 36.89 50% of Eligible Charges OBSERVATION EA ADD HR G0378 HCPCS 762 RC outpatient 43.4 34.72 BCBS Louisiana PPO 34.72 percent of total billed charges 34.72 900 80% of billed charge OBSERVATION EA ADD HR G0378 HCPCS 762 RC outpatient 43.4 34.72 Cigna Commercial PPO 900 other 34.72 900 900 per stay OBSERVATION EA ADD HR G0378 HCPCS 762 RC inpatient 43.4 21.7 IMA of Louisiana Commercial PPO 36.89 percent of total billed charges 21.7 36.89 Inpatient Reimbursement at 85% of Billed Charges OBSERVATION EA ADD HR G0378 HCPCS 762 RC outpatient 43.4 34.72 IMA of Louisiana Commercial PPO 36.89 percent of total billed charges 34.72 900 Reimbursement at 85% of billed charges OBSERVATION EA ADD HR G0378 HCPCS 762 RC outpatient 43.4 34.72 Aetna Commercial PPO 550 case rate 34.72 900 550 Case Rate Once Per Day SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC inpatient 91.8 45.9 BCBS Louisiana PPO 45.9 percent of total billed charges 45.9 78.03 50% of Eligible Charges SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC outpatient 91.8 73.44 BCBS Louisiana PPO 73.44 percent of total billed charges 50.49 78.03 80% of billed charge SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC outpatient 91.8 73.44 Cigna Commercial PPO 50.49 percent of total billed charges 50.49 78.03 55% of Billed Charges SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC inpatient 91.8 45.9 IMA of Louisiana Commercial PPO 78.03 percent of total billed charges 45.9 78.03 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC outpatient 91.8 73.44 IMA of Louisiana Commercial PPO 78.03 percent of total billed charges 50.49 78.03 Reimbursement at 85% of billed charges SUTURE STRATAFIX 3-0 PDO SXPD2B424 272 RC outpatient 91.8 73.44 Aetna Commercial PPO 50.49 percent of total billed charges 50.49 78.03 55 of billed Charges CPM MACHINE 270 RC inpatient 40 20 BCBS Louisiana PPO 20 percent of total billed charges 20 34 50% of Eligible Charges CPM MACHINE 270 RC outpatient 40 32 BCBS Louisiana PPO 32 percent of total billed charges 22 34 80% of billed charge CPM MACHINE 270 RC outpatient 40 32 Cigna Commercial PPO 22 percent of total billed charges 22 34 55% of Billed Charges CPM MACHINE 270 RC inpatient 40 20 IMA of Louisiana Commercial PPO 34 percent of total billed charges 20 34 Inpatient Reimbursement at 85% of Billed Charges CPM MACHINE 270 RC outpatient 40 32 IMA of Louisiana Commercial PPO 34 percent of total billed charges 22 34 Reimbursement at 85% of billed charges CPM MACHINE 270 RC outpatient 40 32 Aetna Commercial PPO 22 percent of total billed charges 22 34 55 of billed Charges ACE ELAST 4 (NON-STERILE) 270 RC inpatient 1.7 0.85 BCBS Louisiana PPO 0.85 percent of total billed charges 0.85 1.45 50% of Eligible Charges ACE ELAST 4 (NON-STERILE) 270 RC outpatient 1.7 1.36 BCBS Louisiana PPO 1.36 percent of total billed charges 0.94 1.45 80% of billed charge ACE ELAST 4 (NON-STERILE) 270 RC outpatient 1.7 1.36 Cigna Commercial PPO 0.94 percent of total billed charges 0.94 1.45 55% of Billed Charges ACE ELAST 4 (NON-STERILE) 270 RC inpatient 1.7 0.85 IMA of Louisiana Commercial PPO 1.45 percent of total billed charges 0.85 1.45 Inpatient Reimbursement at 85% of Billed Charges ACE ELAST 4 (NON-STERILE) 270 RC outpatient 1.7 1.36 IMA of Louisiana Commercial PPO 1.45 percent of total billed charges 0.94 1.45 Reimbursement at 85% of billed charges ACE ELAST 4 (NON-STERILE) 270 RC outpatient 1.7 1.36 Aetna Commercial PPO 0.94 percent of total billed charges 0.94 1.45 55 of billed Charges ACE ELAST 6 (NON-STERILE) 270 RC inpatient 2.49 1.25 BCBS Louisiana PPO 1.25 percent of total billed charges 1.25 2.12 50% of Eligible Charges ACE ELAST 6 (NON-STERILE) 270 RC outpatient 2.49 1.99 BCBS Louisiana PPO 1.99 percent of total billed charges 1.37 2.12 80% of billed charge ACE ELAST 6 (NON-STERILE) 270 RC outpatient 2.49 1.99 Cigna Commercial PPO 1.37 percent of total billed charges 1.37 2.12 55% of Billed Charges ACE ELAST 6 (NON-STERILE) 270 RC inpatient 2.49 1.25 IMA of Louisiana Commercial PPO 2.12 percent of total billed charges 1.25 2.12 Inpatient Reimbursement at 85% of Billed Charges ACE ELAST 6 (NON-STERILE) 270 RC outpatient 2.49 1.99 IMA of Louisiana Commercial PPO 2.12 percent of total billed charges 1.37 2.12 Reimbursement at 85% of billed charges ACE ELAST 6 (NON-STERILE) 270 RC outpatient 2.49 1.99 Aetna Commercial PPO 1.37 percent of total billed charges 1.37 2.12 55 of billed Charges ACE ELAST 6 (STERILE) 272 RC inpatient 180.8 90.4 BCBS Louisiana PPO 90.4 percent of total billed charges 90.4 153.68 50% of Eligible Charges ACE ELAST 6 (STERILE) 272 RC outpatient 180.8 144.64 BCBS Louisiana PPO 144.64 percent of total billed charges 99.44 153.68 80% of billed charge ACE ELAST 6 (STERILE) 272 RC outpatient 180.8 144.64 Cigna Commercial PPO 99.44 percent of total billed charges 99.44 153.68 55% of Billed Charges ACE ELAST 6 (STERILE) 272 RC inpatient 180.8 90.4 IMA of Louisiana Commercial PPO 153.68 percent of total billed charges 90.4 153.68 Inpatient Reimbursement at 85% of Billed Charges ACE ELAST 6 (STERILE) 272 RC outpatient 180.8 144.64 IMA of Louisiana Commercial PPO 153.68 percent of total billed charges 99.44 153.68 Reimbursement at 85% of billed charges ACE ELAST 6 (STERILE) 272 RC outpatient 180.8 144.64 Aetna Commercial PPO 99.44 percent of total billed charges 99.44 153.68 55 of billed Charges AIRWAY BERMAN 80MM 270 RC inpatient 50.36 25.18 BCBS Louisiana PPO 25.18 percent of total billed charges 25.18 42.81 50% of Eligible Charges AIRWAY BERMAN 80MM 270 RC outpatient 50.36 40.29 BCBS Louisiana PPO 40.29 percent of total billed charges 27.7 42.81 80% of billed charge AIRWAY BERMAN 80MM 270 RC outpatient 50.36 40.29 Cigna Commercial PPO 27.7 percent of total billed charges 27.7 42.81 55% of Billed Charges AIRWAY BERMAN 80MM 270 RC inpatient 50.36 25.18 IMA of Louisiana Commercial PPO 42.81 percent of total billed charges 25.18 42.81 Inpatient Reimbursement at 85% of Billed Charges AIRWAY BERMAN 80MM 270 RC outpatient 50.36 40.29 IMA of Louisiana Commercial PPO 42.81 percent of total billed charges 27.7 42.81 Reimbursement at 85% of billed charges AIRWAY BERMAN 80MM 270 RC outpatient 50.36 40.29 Aetna Commercial PPO 27.7 percent of total billed charges 27.7 42.81 55 of billed Charges AIRWAY NASOPHAR 32 FR 272 RC inpatient 25.96 12.98 BCBS Louisiana PPO 12.98 percent of total billed charges 12.98 22.07 50% of Eligible Charges AIRWAY NASOPHAR 32 FR 272 RC outpatient 25.96 20.77 BCBS Louisiana PPO 20.77 percent of total billed charges 14.28 22.07 80% of billed charge AIRWAY NASOPHAR 32 FR 272 RC outpatient 25.96 20.77 Cigna Commercial PPO 14.28 percent of total billed charges 14.28 22.07 55% of Billed Charges AIRWAY NASOPHAR 32 FR 272 RC inpatient 25.96 12.98 IMA of Louisiana Commercial PPO 22.07 percent of total billed charges 12.98 22.07 Inpatient Reimbursement at 85% of Billed Charges AIRWAY NASOPHAR 32 FR 272 RC outpatient 25.96 20.77 IMA of Louisiana Commercial PPO 22.07 percent of total billed charges 14.28 22.07 Reimbursement at 85% of billed charges AIRWAY NASOPHAR 32 FR 272 RC outpatient 25.96 20.77 Aetna Commercial PPO 14.28 percent of total billed charges 14.28 22.07 55 of billed Charges SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 54MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 WASHER 7.0MM C1713 HCPCS 278 RC inpatient 80 40 BCBS Louisiana PPO 40 percent of total billed charges 40 68 50% of Eligible Charges WASHER 7.0MM C1713 HCPCS 278 RC outpatient 80 64 BCBS Louisiana PPO 64 percent of total billed charges 29.6 68 80% of billed charge WASHER 7.0MM C1713 HCPCS 278 RC outpatient 80 64 Cigna Commercial PPO 46.4 percent of total billed charges 29.6 68 58% of Billed Charges/$500 Threshold WASHER 7.0MM C1713 HCPCS 278 RC inpatient 80 40 IMA of Louisiana Commercial PPO 68 percent of total billed charges 40 68 Inpatient Reimbursement at 85% of Billed Charges WASHER 7.0MM C1713 HCPCS 278 RC outpatient 80 64 IMA of Louisiana Commercial PPO 68 percent of total billed charges 29.6 68 Reimbursement at 85% of billed charges WASHER 7.0MM C1713 HCPCS 278 RC outpatient 80 64 Aetna Commercial PPO 29.6 percent of total billed charges 29.6 68 37% Of Billed Charges 2000 FINGER FOAM SPLINT 1 270 RC inpatient 592 296 BCBS Louisiana PPO 296 percent of total billed charges 296 503.2 50% of Eligible Charges FINGER FOAM SPLINT 1 270 RC outpatient 592 473.6 BCBS Louisiana PPO 473.6 percent of total billed charges 325.6 503.2 80% of billed charge FINGER FOAM SPLINT 1 270 RC outpatient 592 473.6 Cigna Commercial PPO 325.6 percent of total billed charges 325.6 503.2 55% of Billed Charges FINGER FOAM SPLINT 1 270 RC inpatient 592 296 IMA of Louisiana Commercial PPO 503.2 percent of total billed charges 296 503.2 Inpatient Reimbursement at 85% of Billed Charges FINGER FOAM SPLINT 1 270 RC outpatient 592 473.6 IMA of Louisiana Commercial PPO 503.2 percent of total billed charges 325.6 503.2 Reimbursement at 85% of billed charges FINGER FOAM SPLINT 1 270 RC outpatient 592 473.6 Aetna Commercial PPO 325.6 percent of total billed charges 325.6 503.2 55 of billed Charges BANDAGE COBAN 4 STERILE 272 RC inpatient 8.95 4.48 BCBS Louisiana PPO 4.48 percent of total billed charges 4.48 7.61 50% of Eligible Charges BANDAGE COBAN 4 STERILE 272 RC outpatient 8.95 7.16 BCBS Louisiana PPO 7.16 percent of total billed charges 4.92 7.61 80% of billed charge BANDAGE COBAN 4 STERILE 272 RC outpatient 8.95 7.16 Cigna Commercial PPO 4.92 percent of total billed charges 4.92 7.61 55% of Billed Charges BANDAGE COBAN 4 STERILE 272 RC inpatient 8.95 4.48 IMA of Louisiana Commercial PPO 7.61 percent of total billed charges 4.48 7.61 Inpatient Reimbursement at 85% of Billed Charges BANDAGE COBAN 4 STERILE 272 RC outpatient 8.95 7.16 IMA of Louisiana Commercial PPO 7.61 percent of total billed charges 4.92 7.61 Reimbursement at 85% of billed charges BANDAGE COBAN 4 STERILE 272 RC outpatient 8.95 7.16 Aetna Commercial PPO 4.92 percent of total billed charges 4.92 7.61 55 of billed Charges GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC inpatient 459 229.5 BCBS Louisiana PPO 229.5 percent of total billed charges 229.5 390.15 50% of Eligible Charges GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC outpatient 459 367.2 BCBS Louisiana PPO 367.2 percent of total billed charges 252.45 390.15 80% of billed charge GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC outpatient 459 367.2 Cigna Commercial PPO 252.45 percent of total billed charges 252.45 390.15 55% of Billed Charges GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC inpatient 459 229.5 IMA of Louisiana Commercial PPO 390.15 percent of total billed charges 229.5 390.15 Inpatient Reimbursement at 85% of Billed Charges GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC outpatient 459 367.2 IMA of Louisiana Commercial PPO 390.15 percent of total billed charges 252.45 390.15 Reimbursement at 85% of billed charges GLOVE ANSELL RADIATION ATTENU SZ 7.5 272 RC outpatient 459 367.2 Aetna Commercial PPO 252.45 percent of total billed charges 252.45 390.15 55 of billed Charges SUTURE 3-0 MONOCRYL SH Y416H 272 RC inpatient 9.04 4.52 BCBS Louisiana PPO 4.52 percent of total billed charges 4.52 7.68 50% of Eligible Charges SUTURE 3-0 MONOCRYL SH Y416H 272 RC outpatient 9.04 7.23 BCBS Louisiana PPO 7.23 percent of total billed charges 4.97 7.68 80% of billed charge SUTURE 3-0 MONOCRYL SH Y416H 272 RC outpatient 9.04 7.23 Cigna Commercial PPO 4.97 percent of total billed charges 4.97 7.68 55% of Billed Charges SUTURE 3-0 MONOCRYL SH Y416H 272 RC inpatient 9.04 4.52 IMA of Louisiana Commercial PPO 7.68 percent of total billed charges 4.52 7.68 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 MONOCRYL SH Y416H 272 RC outpatient 9.04 7.23 IMA of Louisiana Commercial PPO 7.68 percent of total billed charges 4.97 7.68 Reimbursement at 85% of billed charges SUTURE 3-0 MONOCRYL SH Y416H 272 RC outpatient 9.04 7.23 Aetna Commercial PPO 4.97 percent of total billed charges 4.97 7.68 55 of billed Charges CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC inpatient 570.35 285.18 BCBS Louisiana PPO 285.18 percent of total billed charges 285.18 484.8 50% of Eligible Charges CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 BCBS Louisiana PPO 456.28 percent of total billed charges 313.69 484.8 80% of billed charge CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 Cigna Commercial PPO 313.69 percent of total billed charges 313.69 484.8 55% of Billed Charges CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC inpatient 570.35 285.18 IMA of Louisiana Commercial PPO 484.8 percent of total billed charges 285.18 484.8 Inpatient Reimbursement at 85% of Billed Charges CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 IMA of Louisiana Commercial PPO 484.8 percent of total billed charges 313.69 484.8 Reimbursement at 85% of billed charges CATHETER INTROCAN 18G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 Aetna Commercial PPO 313.69 percent of total billed charges 313.69 484.8 55 of billed Charges CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC inpatient 570.35 285.18 BCBS Louisiana PPO 285.18 percent of total billed charges 285.18 484.8 50% of Eligible Charges CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 BCBS Louisiana PPO 456.28 percent of total billed charges 313.69 484.8 80% of billed charge CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 Cigna Commercial PPO 313.69 percent of total billed charges 313.69 484.8 55% of Billed Charges CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC inpatient 570.35 285.18 IMA of Louisiana Commercial PPO 484.8 percent of total billed charges 285.18 484.8 Inpatient Reimbursement at 85% of Billed Charges CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 IMA of Louisiana Commercial PPO 484.8 percent of total billed charges 313.69 484.8 Reimbursement at 85% of billed charges CATHETER INTROCAN 20G 1 3/4 - ANESTHESIA 272 RC outpatient 570.35 456.28 Aetna Commercial PPO 313.69 percent of total billed charges 313.69 484.8 55 of billed Charges CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC inpatient 594.16 297.08 BCBS Louisiana PPO 297.08 percent of total billed charges 297.08 505.04 50% of Eligible Charges CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC outpatient 594.16 475.33 BCBS Louisiana PPO 475.33 percent of total billed charges 326.79 505.04 80% of billed charge CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC outpatient 594.16 475.33 Cigna Commercial PPO 326.79 percent of total billed charges 326.79 505.04 55% of Billed Charges CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC inpatient 594.16 297.08 IMA of Louisiana Commercial PPO 505.04 percent of total billed charges 297.08 505.04 Inpatient Reimbursement at 85% of Billed Charges CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC outpatient 594.16 475.33 IMA of Louisiana Commercial PPO 505.04 percent of total billed charges 326.79 505.04 Reimbursement at 85% of billed charges CHEST TUBE TRAY 20 FR C1729 HCPCS 272 RC outpatient 594.16 475.33 Aetna Commercial PPO 326.79 percent of total billed charges 326.79 505.04 55 of billed Charges BOXER SHORTS LARGE 3RD FLOOR 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges BOXER SHORTS LARGE 3RD FLOOR 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge BOXER SHORTS LARGE 3RD FLOOR 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges BOXER SHORTS LARGE 3RD FLOOR 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges BOXER SHORTS LARGE 3RD FLOOR 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges BOXER SHORTS LARGE 3RD FLOOR 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUTURE 2 TI-CRON HOS-12 272 RC inpatient 57.04 28.52 BCBS Louisiana PPO 28.52 percent of total billed charges 28.52 48.48 50% of Eligible Charges SUTURE 2 TI-CRON HOS-12 272 RC outpatient 57.04 45.63 BCBS Louisiana PPO 45.63 percent of total billed charges 31.37 48.48 80% of billed charge SUTURE 2 TI-CRON HOS-12 272 RC outpatient 57.04 45.63 Cigna Commercial PPO 31.37 percent of total billed charges 31.37 48.48 55% of Billed Charges SUTURE 2 TI-CRON HOS-12 272 RC inpatient 57.04 28.52 IMA of Louisiana Commercial PPO 48.48 percent of total billed charges 28.52 48.48 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2 TI-CRON HOS-12 272 RC outpatient 57.04 45.63 IMA of Louisiana Commercial PPO 48.48 percent of total billed charges 31.37 48.48 Reimbursement at 85% of billed charges SUTURE 2 TI-CRON HOS-12 272 RC outpatient 57.04 45.63 Aetna Commercial PPO 31.37 percent of total billed charges 31.37 48.48 55 of billed Charges COTTON TIP APPLICATOR 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges COTTON TIP APPLICATOR 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge COTTON TIP APPLICATOR 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges COTTON TIP APPLICATOR 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges COTTON TIP APPLICATOR 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges COTTON TIP APPLICATOR 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges DRAPE IOBAN LONG 272 RC inpatient 58.23 29.12 BCBS Louisiana PPO 29.12 percent of total billed charges 29.12 49.5 50% of Eligible Charges DRAPE IOBAN LONG 272 RC outpatient 58.23 46.58 BCBS Louisiana PPO 46.58 percent of total billed charges 32.03 49.5 80% of billed charge DRAPE IOBAN LONG 272 RC outpatient 58.23 46.58 Cigna Commercial PPO 32.03 percent of total billed charges 32.03 49.5 55% of Billed Charges DRAPE IOBAN LONG 272 RC inpatient 58.23 29.12 IMA of Louisiana Commercial PPO 49.5 percent of total billed charges 29.12 49.5 Inpatient Reimbursement at 85% of Billed Charges DRAPE IOBAN LONG 272 RC outpatient 58.23 46.58 IMA of Louisiana Commercial PPO 49.5 percent of total billed charges 32.03 49.5 Reimbursement at 85% of billed charges DRAPE IOBAN LONG 272 RC outpatient 58.23 46.58 Aetna Commercial PPO 32.03 percent of total billed charges 32.03 49.5 55 of billed Charges DRAPE SPLIT SHEET IMPERVIOUS 272 RC inpatient 10.92 5.46 BCBS Louisiana PPO 5.46 percent of total billed charges 5.46 9.28 50% of Eligible Charges DRAPE SPLIT SHEET IMPERVIOUS 272 RC outpatient 10.92 8.74 BCBS Louisiana PPO 8.74 percent of total billed charges 6.01 9.28 80% of billed charge DRAPE SPLIT SHEET IMPERVIOUS 272 RC outpatient 10.92 8.74 Cigna Commercial PPO 6.01 percent of total billed charges 6.01 9.28 55% of Billed Charges DRAPE SPLIT SHEET IMPERVIOUS 272 RC inpatient 10.92 5.46 IMA of Louisiana Commercial PPO 9.28 percent of total billed charges 5.46 9.28 Inpatient Reimbursement at 85% of Billed Charges DRAPE SPLIT SHEET IMPERVIOUS 272 RC outpatient 10.92 8.74 IMA of Louisiana Commercial PPO 9.28 percent of total billed charges 6.01 9.28 Reimbursement at 85% of billed charges DRAPE SPLIT SHEET IMPERVIOUS 272 RC outpatient 10.92 8.74 Aetna Commercial PPO 6.01 percent of total billed charges 6.01 9.28 55 of billed Charges SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 212.136 C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 ELECTROCAUTERY 0014M (6 1/2 ) 272 RC inpatient 45 22.5 BCBS Louisiana PPO 22.5 percent of total billed charges 22.5 38.25 50% of Eligible Charges ELECTROCAUTERY 0014M (6 1/2 ) 272 RC outpatient 45 36 BCBS Louisiana PPO 36 percent of total billed charges 24.75 38.25 80% of billed charge ELECTROCAUTERY 0014M (6 1/2 ) 272 RC outpatient 45 36 Cigna Commercial PPO 24.75 percent of total billed charges 24.75 38.25 55% of Billed Charges ELECTROCAUTERY 0014M (6 1/2 ) 272 RC inpatient 45 22.5 IMA of Louisiana Commercial PPO 38.25 percent of total billed charges 22.5 38.25 Inpatient Reimbursement at 85% of Billed Charges ELECTROCAUTERY 0014M (6 1/2 ) 272 RC outpatient 45 36 IMA of Louisiana Commercial PPO 38.25 percent of total billed charges 24.75 38.25 Reimbursement at 85% of billed charges ELECTROCAUTERY 0014M (6 1/2 ) 272 RC outpatient 45 36 Aetna Commercial PPO 24.75 percent of total billed charges 24.75 38.25 55 of billed Charges SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 GLOVE ORTHO 7.0 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges GLOVE ORTHO 7.0 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge GLOVE ORTHO 7.0 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges GLOVE ORTHO 7.0 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges GLOVE ORTHO 7.0 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges GLOVE ORTHO 7.0 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges GLOVE STERILE 8.5 LTX 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges GLOVE STERILE 8.5 LTX 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge GLOVE STERILE 8.5 LTX 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges GLOVE STERILE 8.5 LTX 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 8.5 LTX 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges GLOVE STERILE 8.5 LTX 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges GLUCOSE ELITE TEST STRIPS 270 RC inpatient 85.72 42.86 BCBS Louisiana PPO 42.86 percent of total billed charges 42.86 72.86 50% of Eligible Charges GLUCOSE ELITE TEST STRIPS 270 RC outpatient 85.72 68.58 BCBS Louisiana PPO 68.58 percent of total billed charges 47.15 72.86 80% of billed charge GLUCOSE ELITE TEST STRIPS 270 RC outpatient 85.72 68.58 Cigna Commercial PPO 47.15 percent of total billed charges 47.15 72.86 55% of Billed Charges GLUCOSE ELITE TEST STRIPS 270 RC inpatient 85.72 42.86 IMA of Louisiana Commercial PPO 72.86 percent of total billed charges 42.86 72.86 Inpatient Reimbursement at 85% of Billed Charges GLUCOSE ELITE TEST STRIPS 270 RC outpatient 85.72 68.58 IMA of Louisiana Commercial PPO 72.86 percent of total billed charges 47.15 72.86 Reimbursement at 85% of billed charges GLUCOSE ELITE TEST STRIPS 270 RC outpatient 85.72 68.58 Aetna Commercial PPO 47.15 percent of total billed charges 47.15 72.86 55 of billed Charges IV ADMIN SET 102 272 RC inpatient 421.68 210.84 BCBS Louisiana PPO 210.84 percent of total billed charges 210.84 358.43 50% of Eligible Charges IV ADMIN SET 102 272 RC outpatient 421.68 337.34 BCBS Louisiana PPO 337.34 percent of total billed charges 231.92 358.43 80% of billed charge IV ADMIN SET 102 272 RC outpatient 421.68 337.34 Cigna Commercial PPO 231.92 percent of total billed charges 231.92 358.43 55% of Billed Charges IV ADMIN SET 102 272 RC inpatient 421.68 210.84 IMA of Louisiana Commercial PPO 358.43 percent of total billed charges 210.84 358.43 Inpatient Reimbursement at 85% of Billed Charges IV ADMIN SET 102 272 RC outpatient 421.68 337.34 IMA of Louisiana Commercial PPO 358.43 percent of total billed charges 231.92 358.43 Reimbursement at 85% of billed charges IV ADMIN SET 102 272 RC outpatient 421.68 337.34 Aetna Commercial PPO 231.92 percent of total billed charges 231.92 358.43 55 of billed Charges SUCTION TUBING 10FT 272 RC inpatient 8.24 4.12 BCBS Louisiana PPO 4.12 percent of total billed charges 4.12 7 50% of Eligible Charges SUCTION TUBING 10FT 272 RC outpatient 8.24 6.59 BCBS Louisiana PPO 6.59 percent of total billed charges 4.53 7 80% of billed charge SUCTION TUBING 10FT 272 RC outpatient 8.24 6.59 Cigna Commercial PPO 4.53 percent of total billed charges 4.53 7 55% of Billed Charges SUCTION TUBING 10FT 272 RC inpatient 8.24 4.12 IMA of Louisiana Commercial PPO 7 percent of total billed charges 4.12 7 Inpatient Reimbursement at 85% of Billed Charges SUCTION TUBING 10FT 272 RC outpatient 8.24 6.59 IMA of Louisiana Commercial PPO 7 percent of total billed charges 4.53 7 Reimbursement at 85% of billed charges SUCTION TUBING 10FT 272 RC outpatient 8.24 6.59 Aetna Commercial PPO 4.53 percent of total billed charges 4.53 7 55 of billed Charges KLING 2 CONFORM 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges KLING 2 CONFORM 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge KLING 2 CONFORM 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges KLING 2 CONFORM 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges KLING 2 CONFORM 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges KLING 2 CONFORM 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges DRILL BIT 2.8MM - SYN 272 RC inpatient 258.48 129.24 BCBS Louisiana PPO 129.24 percent of total billed charges 129.24 219.71 50% of Eligible Charges DRILL BIT 2.8MM - SYN 272 RC outpatient 258.48 206.78 BCBS Louisiana PPO 206.78 percent of total billed charges 142.16 219.71 80% of billed charge DRILL BIT 2.8MM - SYN 272 RC outpatient 258.48 206.78 Cigna Commercial PPO 142.16 percent of total billed charges 142.16 219.71 55% of Billed Charges DRILL BIT 2.8MM - SYN 272 RC inpatient 258.48 129.24 IMA of Louisiana Commercial PPO 219.71 percent of total billed charges 129.24 219.71 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.8MM - SYN 272 RC outpatient 258.48 206.78 IMA of Louisiana Commercial PPO 219.71 percent of total billed charges 142.16 219.71 Reimbursement at 85% of billed charges DRILL BIT 2.8MM - SYN 272 RC outpatient 258.48 206.78 Aetna Commercial PPO 142.16 percent of total billed charges 142.16 219.71 55 of billed Charges K-WIRE NON-THREADED .045 272 RC inpatient 112.8 56.4 BCBS Louisiana PPO 56.4 percent of total billed charges 56.4 95.88 50% of Eligible Charges K-WIRE NON-THREADED .045 272 RC outpatient 112.8 90.24 BCBS Louisiana PPO 90.24 percent of total billed charges 62.04 95.88 80% of billed charge K-WIRE NON-THREADED .045 272 RC outpatient 112.8 90.24 Cigna Commercial PPO 62.04 percent of total billed charges 62.04 95.88 55% of Billed Charges K-WIRE NON-THREADED .045 272 RC inpatient 112.8 56.4 IMA of Louisiana Commercial PPO 95.88 percent of total billed charges 56.4 95.88 Inpatient Reimbursement at 85% of Billed Charges K-WIRE NON-THREADED .045 272 RC outpatient 112.8 90.24 IMA of Louisiana Commercial PPO 95.88 percent of total billed charges 62.04 95.88 Reimbursement at 85% of billed charges K-WIRE NON-THREADED .045 272 RC outpatient 112.8 90.24 Aetna Commercial PPO 62.04 percent of total billed charges 62.04 95.88 55 of billed Charges K-WIRE THREADED .062 272 RC inpatient 460.25 230.13 BCBS Louisiana PPO 230.13 percent of total billed charges 230.13 391.21 50% of Eligible Charges K-WIRE THREADED .062 272 RC outpatient 460.25 368.2 BCBS Louisiana PPO 368.2 percent of total billed charges 253.14 391.21 80% of billed charge K-WIRE THREADED .062 272 RC outpatient 460.25 368.2 Cigna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55% of Billed Charges K-WIRE THREADED .062 272 RC inpatient 460.25 230.13 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 230.13 391.21 Inpatient Reimbursement at 85% of Billed Charges K-WIRE THREADED .062 272 RC outpatient 460.25 368.2 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 253.14 391.21 Reimbursement at 85% of billed charges K-WIRE THREADED .062 272 RC outpatient 460.25 368.2 Aetna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55 of billed Charges DRILL BIT 2.7MM 272 RC inpatient 588.84 294.42 BCBS Louisiana PPO 294.42 percent of total billed charges 294.42 500.51 50% of Eligible Charges DRILL BIT 2.7MM 272 RC outpatient 588.84 471.07 BCBS Louisiana PPO 471.07 percent of total billed charges 323.86 500.51 80% of billed charge DRILL BIT 2.7MM 272 RC outpatient 588.84 471.07 Cigna Commercial PPO 323.86 percent of total billed charges 323.86 500.51 55% of Billed Charges DRILL BIT 2.7MM 272 RC inpatient 588.84 294.42 IMA of Louisiana Commercial PPO 500.51 percent of total billed charges 294.42 500.51 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.7MM 272 RC outpatient 588.84 471.07 IMA of Louisiana Commercial PPO 500.51 percent of total billed charges 323.86 500.51 Reimbursement at 85% of billed charges DRILL BIT 2.7MM 272 RC outpatient 588.84 471.07 Aetna Commercial PPO 323.86 percent of total billed charges 323.86 500.51 55 of billed Charges NEEDLE CHIBA 22G X 20CM 272 RC inpatient 40.16 20.08 BCBS Louisiana PPO 20.08 percent of total billed charges 20.08 34.14 50% of Eligible Charges NEEDLE CHIBA 22G X 20CM 272 RC outpatient 40.16 32.13 BCBS Louisiana PPO 32.13 percent of total billed charges 22.09 34.14 80% of billed charge NEEDLE CHIBA 22G X 20CM 272 RC outpatient 40.16 32.13 Cigna Commercial PPO 22.09 percent of total billed charges 22.09 34.14 55% of Billed Charges NEEDLE CHIBA 22G X 20CM 272 RC inpatient 40.16 20.08 IMA of Louisiana Commercial PPO 34.14 percent of total billed charges 20.08 34.14 Inpatient Reimbursement at 85% of Billed Charges NEEDLE CHIBA 22G X 20CM 272 RC outpatient 40.16 32.13 IMA of Louisiana Commercial PPO 34.14 percent of total billed charges 22.09 34.14 Reimbursement at 85% of billed charges NEEDLE CHIBA 22G X 20CM 272 RC outpatient 40.16 32.13 Aetna Commercial PPO 22.09 percent of total billed charges 22.09 34.14 55 of billed Charges NEEDLE SPINAL 22G X 3 1/2 272 RC inpatient 8.08 4.04 BCBS Louisiana PPO 4.04 percent of total billed charges 4.04 6.87 50% of Eligible Charges NEEDLE SPINAL 22G X 3 1/2 272 RC outpatient 8.08 6.46 BCBS Louisiana PPO 6.46 percent of total billed charges 4.44 6.87 80% of billed charge NEEDLE SPINAL 22G X 3 1/2 272 RC outpatient 8.08 6.46 Cigna Commercial PPO 4.44 percent of total billed charges 4.44 6.87 55% of Billed Charges NEEDLE SPINAL 22G X 3 1/2 272 RC inpatient 8.08 4.04 IMA of Louisiana Commercial PPO 6.87 percent of total billed charges 4.04 6.87 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 22G X 3 1/2 272 RC outpatient 8.08 6.46 IMA of Louisiana Commercial PPO 6.87 percent of total billed charges 4.44 6.87 Reimbursement at 85% of billed charges NEEDLE SPINAL 22G X 3 1/2 272 RC outpatient 8.08 6.46 Aetna Commercial PPO 4.44 percent of total billed charges 4.44 6.87 55 of billed Charges NEEDLE SPINAL QUINCKE 22G X 5 272 RC inpatient 27.56 13.78 BCBS Louisiana PPO 13.78 percent of total billed charges 13.78 23.43 50% of Eligible Charges NEEDLE SPINAL QUINCKE 22G X 5 272 RC outpatient 27.56 22.05 BCBS Louisiana PPO 22.05 percent of total billed charges 15.16 23.43 80% of billed charge NEEDLE SPINAL QUINCKE 22G X 5 272 RC outpatient 27.56 22.05 Cigna Commercial PPO 15.16 percent of total billed charges 15.16 23.43 55% of Billed Charges NEEDLE SPINAL QUINCKE 22G X 5 272 RC inpatient 27.56 13.78 IMA of Louisiana Commercial PPO 23.43 percent of total billed charges 13.78 23.43 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL QUINCKE 22G X 5 272 RC outpatient 27.56 22.05 IMA of Louisiana Commercial PPO 23.43 percent of total billed charges 15.16 23.43 Reimbursement at 85% of billed charges NEEDLE SPINAL QUINCKE 22G X 5 272 RC outpatient 27.56 22.05 Aetna Commercial PPO 15.16 percent of total billed charges 15.16 23.43 55 of billed Charges PLASTER SPLINT 4 X 15 FAST 270 RC inpatient 37.84 18.92 BCBS Louisiana PPO 18.92 percent of total billed charges 18.92 32.16 50% of Eligible Charges PLASTER SPLINT 4 X 15 FAST 270 RC outpatient 37.84 30.27 BCBS Louisiana PPO 30.27 percent of total billed charges 20.81 32.16 80% of billed charge PLASTER SPLINT 4 X 15 FAST 270 RC outpatient 37.84 30.27 Cigna Commercial PPO 20.81 percent of total billed charges 20.81 32.16 55% of Billed Charges PLASTER SPLINT 4 X 15 FAST 270 RC inpatient 37.84 18.92 IMA of Louisiana Commercial PPO 32.16 percent of total billed charges 18.92 32.16 Inpatient Reimbursement at 85% of Billed Charges PLASTER SPLINT 4 X 15 FAST 270 RC outpatient 37.84 30.27 IMA of Louisiana Commercial PPO 32.16 percent of total billed charges 20.81 32.16 Reimbursement at 85% of billed charges PLASTER SPLINT 4 X 15 FAST 270 RC outpatient 37.84 30.27 Aetna Commercial PPO 20.81 percent of total billed charges 20.81 32.16 55 of billed Charges TOURNIQUET 24 DISPOSABLE 272 RC inpatient 499.03 249.52 BCBS Louisiana PPO 249.52 percent of total billed charges 249.52 424.18 50% of Eligible Charges TOURNIQUET 24 DISPOSABLE 272 RC outpatient 499.03 399.22 BCBS Louisiana PPO 399.22 percent of total billed charges 274.47 424.18 80% of billed charge TOURNIQUET 24 DISPOSABLE 272 RC outpatient 499.03 399.22 Cigna Commercial PPO 274.47 percent of total billed charges 274.47 424.18 55% of Billed Charges TOURNIQUET 24 DISPOSABLE 272 RC inpatient 499.03 249.52 IMA of Louisiana Commercial PPO 424.18 percent of total billed charges 249.52 424.18 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 24 DISPOSABLE 272 RC outpatient 499.03 399.22 IMA of Louisiana Commercial PPO 424.18 percent of total billed charges 274.47 424.18 Reimbursement at 85% of billed charges TOURNIQUET 24 DISPOSABLE 272 RC outpatient 499.03 399.22 Aetna Commercial PPO 274.47 percent of total billed charges 274.47 424.18 55 of billed Charges SHOE POST-OP FEMALE MED 270 RC inpatient 28.32 14.16 BCBS Louisiana PPO 14.16 percent of total billed charges 14.16 24.07 50% of Eligible Charges SHOE POST-OP FEMALE MED 270 RC outpatient 28.32 22.66 BCBS Louisiana PPO 22.66 percent of total billed charges 15.58 24.07 80% of billed charge SHOE POST-OP FEMALE MED 270 RC outpatient 28.32 22.66 Cigna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55% of Billed Charges SHOE POST-OP FEMALE MED 270 RC inpatient 28.32 14.16 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 14.16 24.07 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP FEMALE MED 270 RC outpatient 28.32 22.66 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 15.58 24.07 Reimbursement at 85% of billed charges SHOE POST-OP FEMALE MED 270 RC outpatient 28.32 22.66 Aetna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55 of billed Charges SUTURE LASSO 25 DEGREE LEFT 272 RC inpatient 507.5 253.75 BCBS Louisiana PPO 253.75 percent of total billed charges 253.75 431.38 50% of Eligible Charges SUTURE LASSO 25 DEGREE LEFT 272 RC outpatient 507.5 406 BCBS Louisiana PPO 406 percent of total billed charges 279.13 431.38 80% of billed charge SUTURE LASSO 25 DEGREE LEFT 272 RC outpatient 507.5 406 Cigna Commercial PPO 279.13 percent of total billed charges 279.13 431.38 55% of Billed Charges SUTURE LASSO 25 DEGREE LEFT 272 RC inpatient 507.5 253.75 IMA of Louisiana Commercial PPO 431.38 percent of total billed charges 253.75 431.38 Inpatient Reimbursement at 85% of Billed Charges SUTURE LASSO 25 DEGREE LEFT 272 RC outpatient 507.5 406 IMA of Louisiana Commercial PPO 431.38 percent of total billed charges 279.13 431.38 Reimbursement at 85% of billed charges SUTURE LASSO 25 DEGREE LEFT 272 RC outpatient 507.5 406 Aetna Commercial PPO 279.13 percent of total billed charges 279.13 431.38 55 of billed Charges ICE PACK - SMALL 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges ICE PACK - SMALL 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge ICE PACK - SMALL 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges ICE PACK - SMALL 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges ICE PACK - SMALL 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges ICE PACK - SMALL 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SAW BLADE SP-511 272 RC inpatient 68 34 BCBS Louisiana PPO 34 percent of total billed charges 34 57.8 50% of Eligible Charges SAW BLADE SP-511 272 RC outpatient 68 54.4 BCBS Louisiana PPO 54.4 percent of total billed charges 37.4 57.8 80% of billed charge SAW BLADE SP-511 272 RC outpatient 68 54.4 Cigna Commercial PPO 37.4 percent of total billed charges 37.4 57.8 55% of Billed Charges SAW BLADE SP-511 272 RC inpatient 68 34 IMA of Louisiana Commercial PPO 57.8 percent of total billed charges 34 57.8 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE SP-511 272 RC outpatient 68 54.4 IMA of Louisiana Commercial PPO 57.8 percent of total billed charges 37.4 57.8 Reimbursement at 85% of billed charges SAW BLADE SP-511 272 RC outpatient 68 54.4 Aetna Commercial PPO 37.4 percent of total billed charges 37.4 57.8 55 of billed Charges SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 113.82 56.91 BCBS Louisiana PPO 56.91 percent of total billed charges 56.91 96.75 50% of Eligible Charges SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 BCBS Louisiana PPO 91.06 percent of total billed charges 42.11 96.75 80% of billed charge SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 Cigna Commercial PPO 66.02 percent of total billed charges 42.11 96.75 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 113.82 56.91 IMA of Louisiana Commercial PPO 96.75 percent of total billed charges 56.91 96.75 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 IMA of Louisiana Commercial PPO 96.75 percent of total billed charges 42.11 96.75 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 12MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 113.82 91.06 Aetna Commercial PPO 42.11 percent of total billed charges 42.11 96.75 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 BUR OVAL 5.5MM 9CM #9OV55 272 RC inpatient 373.1 186.55 BCBS Louisiana PPO 186.55 percent of total billed charges 186.55 317.14 50% of Eligible Charges BUR OVAL 5.5MM 9CM #9OV55 272 RC outpatient 373.1 298.48 BCBS Louisiana PPO 298.48 percent of total billed charges 205.21 317.14 80% of billed charge BUR OVAL 5.5MM 9CM #9OV55 272 RC outpatient 373.1 298.48 Cigna Commercial PPO 205.21 percent of total billed charges 205.21 317.14 55% of Billed Charges BUR OVAL 5.5MM 9CM #9OV55 272 RC inpatient 373.1 186.55 IMA of Louisiana Commercial PPO 317.14 percent of total billed charges 186.55 317.14 Inpatient Reimbursement at 85% of Billed Charges BUR OVAL 5.5MM 9CM #9OV55 272 RC outpatient 373.1 298.48 IMA of Louisiana Commercial PPO 317.14 percent of total billed charges 205.21 317.14 Reimbursement at 85% of billed charges BUR OVAL 5.5MM 9CM #9OV55 272 RC outpatient 373.1 298.48 Aetna Commercial PPO 205.21 percent of total billed charges 205.21 317.14 55 of billed Charges SHOE POST-OP LG 270 RC inpatient 28.32 14.16 BCBS Louisiana PPO 14.16 percent of total billed charges 14.16 24.07 50% of Eligible Charges SHOE POST-OP LG 270 RC outpatient 28.32 22.66 BCBS Louisiana PPO 22.66 percent of total billed charges 15.58 24.07 80% of billed charge SHOE POST-OP LG 270 RC outpatient 28.32 22.66 Cigna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55% of Billed Charges SHOE POST-OP LG 270 RC inpatient 28.32 14.16 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 14.16 24.07 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP LG 270 RC outpatient 28.32 22.66 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 15.58 24.07 Reimbursement at 85% of billed charges SHOE POST-OP LG 270 RC outpatient 28.32 22.66 Aetna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55 of billed Charges SUTURE LASSO CRESENT 272 RC inpatient 490 245 BCBS Louisiana PPO 245 percent of total billed charges 245 416.5 50% of Eligible Charges SUTURE LASSO CRESENT 272 RC outpatient 490 392 BCBS Louisiana PPO 392 percent of total billed charges 269.5 416.5 80% of billed charge SUTURE LASSO CRESENT 272 RC outpatient 490 392 Cigna Commercial PPO 269.5 percent of total billed charges 269.5 416.5 55% of Billed Charges SUTURE LASSO CRESENT 272 RC inpatient 490 245 IMA of Louisiana Commercial PPO 416.5 percent of total billed charges 245 416.5 Inpatient Reimbursement at 85% of Billed Charges SUTURE LASSO CRESENT 272 RC outpatient 490 392 IMA of Louisiana Commercial PPO 416.5 percent of total billed charges 269.5 416.5 Reimbursement at 85% of billed charges SUTURE LASSO CRESENT 272 RC outpatient 490 392 Aetna Commercial PPO 269.5 percent of total billed charges 269.5 416.5 55 of billed Charges STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC inpatient 261.73 130.87 BCBS Louisiana PPO 130.87 percent of total billed charges 130.87 222.47 50% of Eligible Charges STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC outpatient 261.73 209.38 BCBS Louisiana PPO 209.38 percent of total billed charges 143.95 222.47 80% of billed charge STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC outpatient 261.73 209.38 Cigna Commercial PPO 143.95 percent of total billed charges 143.95 222.47 55% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC inpatient 261.73 130.87 IMA of Louisiana Commercial PPO 222.47 percent of total billed charges 130.87 222.47 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC outpatient 261.73 209.38 IMA of Louisiana Commercial PPO 222.47 percent of total billed charges 143.95 222.47 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM LNG THIGH MED 270 RC outpatient 261.73 209.38 Aetna Commercial PPO 143.95 percent of total billed charges 143.95 222.47 55 of billed Charges STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC inpatient 26.56 13.28 BCBS Louisiana PPO 13.28 percent of total billed charges 13.28 22.58 50% of Eligible Charges STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC outpatient 26.56 21.25 BCBS Louisiana PPO 21.25 percent of total billed charges 14.61 22.58 80% of billed charge STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC outpatient 26.56 21.25 Cigna Commercial PPO 14.61 percent of total billed charges 14.61 22.58 55% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC inpatient 26.56 13.28 IMA of Louisiana Commercial PPO 22.58 percent of total billed charges 13.28 22.58 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC outpatient 26.56 21.25 IMA of Louisiana Commercial PPO 22.58 percent of total billed charges 14.61 22.58 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM REG THIGH SM 270 RC outpatient 26.56 21.25 Aetna Commercial PPO 14.61 percent of total billed charges 14.61 22.58 55 of billed Charges STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC inpatient 27.52 13.76 BCBS Louisiana PPO 13.76 percent of total billed charges 13.76 23.39 50% of Eligible Charges STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC outpatient 27.52 22.02 BCBS Louisiana PPO 22.02 percent of total billed charges 15.14 23.39 80% of billed charge STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC outpatient 27.52 22.02 Cigna Commercial PPO 15.14 percent of total billed charges 15.14 23.39 55% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC inpatient 27.52 13.76 IMA of Louisiana Commercial PPO 23.39 percent of total billed charges 13.76 23.39 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC outpatient 27.52 22.02 IMA of Louisiana Commercial PPO 23.39 percent of total billed charges 15.14 23.39 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM REG THIGH XLG 270 RC outpatient 27.52 22.02 Aetna Commercial PPO 15.14 percent of total billed charges 15.14 23.39 55 of billed Charges BONE MILL - MEDTRONIC 272 RC inpatient 504.9 252.45 BCBS Louisiana PPO 252.45 percent of total billed charges 252.45 429.17 50% of Eligible Charges BONE MILL - MEDTRONIC 272 RC outpatient 504.9 403.92 BCBS Louisiana PPO 403.92 percent of total billed charges 277.7 429.17 80% of billed charge BONE MILL - MEDTRONIC 272 RC outpatient 504.9 403.92 Cigna Commercial PPO 277.7 percent of total billed charges 277.7 429.17 55% of Billed Charges BONE MILL - MEDTRONIC 272 RC inpatient 504.9 252.45 IMA of Louisiana Commercial PPO 429.17 percent of total billed charges 252.45 429.17 Inpatient Reimbursement at 85% of Billed Charges BONE MILL - MEDTRONIC 272 RC outpatient 504.9 403.92 IMA of Louisiana Commercial PPO 429.17 percent of total billed charges 277.7 429.17 Reimbursement at 85% of billed charges BONE MILL - MEDTRONIC 272 RC outpatient 504.9 403.92 Aetna Commercial PPO 277.7 percent of total billed charges 277.7 429.17 55 of billed Charges SUTURE 0 VICRYL CT-2 CR J727D 272 RC inpatient 48.6 24.3 BCBS Louisiana PPO 24.3 percent of total billed charges 24.3 41.31 50% of Eligible Charges SUTURE 0 VICRYL CT-2 CR J727D 272 RC outpatient 48.6 38.88 BCBS Louisiana PPO 38.88 percent of total billed charges 26.73 41.31 80% of billed charge SUTURE 0 VICRYL CT-2 CR J727D 272 RC outpatient 48.6 38.88 Cigna Commercial PPO 26.73 percent of total billed charges 26.73 41.31 55% of Billed Charges SUTURE 0 VICRYL CT-2 CR J727D 272 RC inpatient 48.6 24.3 IMA of Louisiana Commercial PPO 41.31 percent of total billed charges 24.3 41.31 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CT-2 CR J727D 272 RC outpatient 48.6 38.88 IMA of Louisiana Commercial PPO 41.31 percent of total billed charges 26.73 41.31 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CT-2 CR J727D 272 RC outpatient 48.6 38.88 Aetna Commercial PPO 26.73 percent of total billed charges 26.73 41.31 55 of billed Charges SUTURE 1 VICRYL CT-1 J261H 272 RC inpatient 6.64 3.32 BCBS Louisiana PPO 3.32 percent of total billed charges 3.32 5.64 50% of Eligible Charges SUTURE 1 VICRYL CT-1 J261H 272 RC outpatient 6.64 5.31 BCBS Louisiana PPO 5.31 percent of total billed charges 3.65 5.64 80% of billed charge SUTURE 1 VICRYL CT-1 J261H 272 RC outpatient 6.64 5.31 Cigna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55% of Billed Charges SUTURE 1 VICRYL CT-1 J261H 272 RC inpatient 6.64 3.32 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.32 5.64 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 VICRYL CT-1 J261H 272 RC outpatient 6.64 5.31 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.65 5.64 Reimbursement at 85% of billed charges SUTURE 1 VICRYL CT-1 J261H 272 RC outpatient 6.64 5.31 Aetna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55 of billed Charges SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC inpatient 10.12 5.06 BCBS Louisiana PPO 5.06 percent of total billed charges 5.06 8.6 50% of Eligible Charges SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC outpatient 10.12 8.1 BCBS Louisiana PPO 8.1 percent of total billed charges 5.57 8.6 80% of billed charge SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC outpatient 10.12 8.1 Cigna Commercial PPO 5.57 percent of total billed charges 5.57 8.6 55% of Billed Charges SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC inpatient 10.12 5.06 IMA of Louisiana Commercial PPO 8.6 percent of total billed charges 5.06 8.6 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC outpatient 10.12 8.1 IMA of Louisiana Commercial PPO 8.6 percent of total billed charges 5.57 8.6 Reimbursement at 85% of billed charges SUTURE 2-0 MONOCRYL CT-1 Y945H 272 RC outpatient 10.12 8.1 Aetna Commercial PPO 5.57 percent of total billed charges 5.57 8.6 55 of billed Charges SUTURE 2-0 PDS FS-1 Z443H 272 RC inpatient 16.2 8.1 BCBS Louisiana PPO 8.1 percent of total billed charges 8.1 13.77 50% of Eligible Charges SUTURE 2-0 PDS FS-1 Z443H 272 RC outpatient 16.2 12.96 BCBS Louisiana PPO 12.96 percent of total billed charges 8.91 13.77 80% of billed charge SUTURE 2-0 PDS FS-1 Z443H 272 RC outpatient 16.2 12.96 Cigna Commercial PPO 8.91 percent of total billed charges 8.91 13.77 55% of Billed Charges SUTURE 2-0 PDS FS-1 Z443H 272 RC inpatient 16.2 8.1 IMA of Louisiana Commercial PPO 13.77 percent of total billed charges 8.1 13.77 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 PDS FS-1 Z443H 272 RC outpatient 16.2 12.96 IMA of Louisiana Commercial PPO 13.77 percent of total billed charges 8.91 13.77 Reimbursement at 85% of billed charges SUTURE 2-0 PDS FS-1 Z443H 272 RC outpatient 16.2 12.96 Aetna Commercial PPO 8.91 percent of total billed charges 8.91 13.77 55 of billed Charges FLYTE SHIELDS - STRYKER 272 RC inpatient 905.1 452.55 BCBS Louisiana PPO 452.55 percent of total billed charges 452.55 769.34 50% of Eligible Charges FLYTE SHIELDS - STRYKER 272 RC outpatient 905.1 724.08 BCBS Louisiana PPO 724.08 percent of total billed charges 497.81 769.34 80% of billed charge FLYTE SHIELDS - STRYKER 272 RC outpatient 905.1 724.08 Cigna Commercial PPO 497.81 percent of total billed charges 497.81 769.34 55% of Billed Charges FLYTE SHIELDS - STRYKER 272 RC inpatient 905.1 452.55 IMA of Louisiana Commercial PPO 769.34 percent of total billed charges 452.55 769.34 Inpatient Reimbursement at 85% of Billed Charges FLYTE SHIELDS - STRYKER 272 RC outpatient 905.1 724.08 IMA of Louisiana Commercial PPO 769.34 percent of total billed charges 497.81 769.34 Reimbursement at 85% of billed charges FLYTE SHIELDS - STRYKER 272 RC outpatient 905.1 724.08 Aetna Commercial PPO 497.81 percent of total billed charges 497.81 769.34 55 of billed Charges SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC inpatient 8.54 4.27 BCBS Louisiana PPO 4.27 percent of total billed charges 4.27 7.26 50% of Eligible Charges SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC outpatient 8.54 6.83 BCBS Louisiana PPO 6.83 percent of total billed charges 4.7 7.26 80% of billed charge SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC outpatient 8.54 6.83 Cigna Commercial PPO 4.7 percent of total billed charges 4.7 7.26 55% of Billed Charges SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC inpatient 8.54 4.27 IMA of Louisiana Commercial PPO 7.26 percent of total billed charges 4.27 7.26 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC outpatient 8.54 6.83 IMA of Louisiana Commercial PPO 7.26 percent of total billed charges 4.7 7.26 Reimbursement at 85% of billed charges SUTURE 3-0 ETHIBOND RB-1 X872H 272 RC outpatient 8.54 6.83 Aetna Commercial PPO 4.7 percent of total billed charges 4.7 7.26 55 of billed Charges CATHETER SUCTION 14FR 272 RC inpatient 56.52 28.26 BCBS Louisiana PPO 28.26 percent of total billed charges 28.26 48.04 50% of Eligible Charges CATHETER SUCTION 14FR 272 RC outpatient 56.52 45.22 BCBS Louisiana PPO 45.22 percent of total billed charges 31.09 48.04 80% of billed charge CATHETER SUCTION 14FR 272 RC outpatient 56.52 45.22 Cigna Commercial PPO 31.09 percent of total billed charges 31.09 48.04 55% of Billed Charges CATHETER SUCTION 14FR 272 RC inpatient 56.52 28.26 IMA of Louisiana Commercial PPO 48.04 percent of total billed charges 28.26 48.04 Inpatient Reimbursement at 85% of Billed Charges CATHETER SUCTION 14FR 272 RC outpatient 56.52 45.22 IMA of Louisiana Commercial PPO 48.04 percent of total billed charges 31.09 48.04 Reimbursement at 85% of billed charges CATHETER SUCTION 14FR 272 RC outpatient 56.52 45.22 Aetna Commercial PPO 31.09 percent of total billed charges 31.09 48.04 55 of billed Charges SUTURE STRATAFIX 0 MONODERM #401 272 RC inpatient 90.17 45.09 BCBS Louisiana PPO 45.09 percent of total billed charges 45.09 76.64 50% of Eligible Charges SUTURE STRATAFIX 0 MONODERM #401 272 RC outpatient 90.17 72.14 BCBS Louisiana PPO 72.14 percent of total billed charges 49.59 76.64 80% of billed charge SUTURE STRATAFIX 0 MONODERM #401 272 RC outpatient 90.17 72.14 Cigna Commercial PPO 49.59 percent of total billed charges 49.59 76.64 55% of Billed Charges SUTURE STRATAFIX 0 MONODERM #401 272 RC inpatient 90.17 45.09 IMA of Louisiana Commercial PPO 76.64 percent of total billed charges 45.09 76.64 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX 0 MONODERM #401 272 RC outpatient 90.17 72.14 IMA of Louisiana Commercial PPO 76.64 percent of total billed charges 49.59 76.64 Reimbursement at 85% of billed charges SUTURE STRATAFIX 0 MONODERM #401 272 RC outpatient 90.17 72.14 Aetna Commercial PPO 49.59 percent of total billed charges 49.59 76.64 55 of billed Charges STOCKING KNEE - MEDIUM 270 RC inpatient 134.89 67.45 BCBS Louisiana PPO 67.45 percent of total billed charges 67.45 114.66 50% of Eligible Charges STOCKING KNEE - MEDIUM 270 RC outpatient 134.89 107.91 BCBS Louisiana PPO 107.91 percent of total billed charges 74.19 114.66 80% of billed charge STOCKING KNEE - MEDIUM 270 RC outpatient 134.89 107.91 Cigna Commercial PPO 74.19 percent of total billed charges 74.19 114.66 55% of Billed Charges STOCKING KNEE - MEDIUM 270 RC inpatient 134.89 67.45 IMA of Louisiana Commercial PPO 114.66 percent of total billed charges 67.45 114.66 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - MEDIUM 270 RC outpatient 134.89 107.91 IMA of Louisiana Commercial PPO 114.66 percent of total billed charges 74.19 114.66 Reimbursement at 85% of billed charges STOCKING KNEE - MEDIUM 270 RC outpatient 134.89 107.91 Aetna Commercial PPO 74.19 percent of total billed charges 74.19 114.66 55 of billed Charges SUTURE 4-0 MERSILENE S-2 272 RC inpatient 57.92 28.96 BCBS Louisiana PPO 28.96 percent of total billed charges 28.96 49.23 50% of Eligible Charges SUTURE 4-0 MERSILENE S-2 272 RC outpatient 57.92 46.34 BCBS Louisiana PPO 46.34 percent of total billed charges 31.86 49.23 80% of billed charge SUTURE 4-0 MERSILENE S-2 272 RC outpatient 57.92 46.34 Cigna Commercial PPO 31.86 percent of total billed charges 31.86 49.23 55% of Billed Charges SUTURE 4-0 MERSILENE S-2 272 RC inpatient 57.92 28.96 IMA of Louisiana Commercial PPO 49.23 percent of total billed charges 28.96 49.23 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 MERSILENE S-2 272 RC outpatient 57.92 46.34 IMA of Louisiana Commercial PPO 49.23 percent of total billed charges 31.86 49.23 Reimbursement at 85% of billed charges SUTURE 4-0 MERSILENE S-2 272 RC outpatient 57.92 46.34 Aetna Commercial PPO 31.86 percent of total billed charges 31.86 49.23 55 of billed Charges STOCKING KNEE - LARGE 270 RC inpatient 129.92 64.96 BCBS Louisiana PPO 64.96 percent of total billed charges 64.96 110.43 50% of Eligible Charges STOCKING KNEE - LARGE 270 RC outpatient 129.92 103.94 BCBS Louisiana PPO 103.94 percent of total billed charges 71.46 110.43 80% of billed charge STOCKING KNEE - LARGE 270 RC outpatient 129.92 103.94 Cigna Commercial PPO 71.46 percent of total billed charges 71.46 110.43 55% of Billed Charges STOCKING KNEE - LARGE 270 RC inpatient 129.92 64.96 IMA of Louisiana Commercial PPO 110.43 percent of total billed charges 64.96 110.43 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - LARGE 270 RC outpatient 129.92 103.94 IMA of Louisiana Commercial PPO 110.43 percent of total billed charges 71.46 110.43 Reimbursement at 85% of billed charges STOCKING KNEE - LARGE 270 RC outpatient 129.92 103.94 Aetna Commercial PPO 71.46 percent of total billed charges 71.46 110.43 55 of billed Charges SUTURE 5-0 ETHILON P-3 698H 272 RC inpatient 5.26 2.63 BCBS Louisiana PPO 2.63 percent of total billed charges 2.63 4.47 50% of Eligible Charges SUTURE 5-0 ETHILON P-3 698H 272 RC outpatient 5.26 4.21 BCBS Louisiana PPO 4.21 percent of total billed charges 2.89 4.47 80% of billed charge SUTURE 5-0 ETHILON P-3 698H 272 RC outpatient 5.26 4.21 Cigna Commercial PPO 2.89 percent of total billed charges 2.89 4.47 55% of Billed Charges SUTURE 5-0 ETHILON P-3 698H 272 RC inpatient 5.26 2.63 IMA of Louisiana Commercial PPO 4.47 percent of total billed charges 2.63 4.47 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 ETHILON P-3 698H 272 RC outpatient 5.26 4.21 IMA of Louisiana Commercial PPO 4.47 percent of total billed charges 2.89 4.47 Reimbursement at 85% of billed charges SUTURE 5-0 ETHILON P-3 698H 272 RC outpatient 5.26 4.21 Aetna Commercial PPO 2.89 percent of total billed charges 2.89 4.47 55 of billed Charges SYRINGE 60CC LL 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE 60CC LL 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE 60CC LL 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE 60CC LL 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 60CC LL 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE 60CC LL 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SYRINGE TB 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE TB 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE TB 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE TB 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE TB 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE TB 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges TAPE DURAPORE SILK 1 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges TAPE DURAPORE SILK 1 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge TAPE DURAPORE SILK 1 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges TAPE DURAPORE SILK 1 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges TAPE DURAPORE SILK 1 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges TAPE DURAPORE SILK 1 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUTURE TI-CRON 2-0 CV316 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges SUTURE TI-CRON 2-0 CV316 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge SUTURE TI-CRON 2-0 CV316 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges SUTURE TI-CRON 2-0 CV316 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges SUTURE TI-CRON 2-0 CV316 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges SUTURE TI-CRON 2-0 CV316 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC inpatient 609.3 304.65 BCBS Louisiana PPO 304.65 percent of total billed charges 304.65 517.91 50% of Eligible Charges CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC outpatient 609.3 487.44 BCBS Louisiana PPO 487.44 percent of total billed charges 225.44 517.91 80% of billed charge CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC outpatient 609.3 487.44 Cigna Commercial PPO 353.39 percent of total billed charges 225.44 517.91 58% of Billed Charges/$500 Threshold CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC inpatient 609.3 304.65 IMA of Louisiana Commercial PPO 517.91 percent of total billed charges 304.65 517.91 Inpatient Reimbursement at 85% of Billed Charges CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC outpatient 609.3 487.44 IMA of Louisiana Commercial PPO 517.91 percent of total billed charges 225.44 517.91 Reimbursement at 85% of billed charges CABLE 1.7MM WITH CRIMP -SYNTHES C1713 HCPCS 278 RC outpatient 609.3 487.44 Aetna Commercial PPO 225.44 percent of total billed charges 225.44 517.91 37% Of Billed Charges 2000 BANDAGE COBAN 4 X 5 YRDS 272 RC inpatient 6.4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 3.2 5.44 50% of Eligible Charges BANDAGE COBAN 4 X 5 YRDS 272 RC outpatient 6.4 5.12 BCBS Louisiana PPO 5.12 percent of total billed charges 3.52 5.44 80% of billed charge BANDAGE COBAN 4 X 5 YRDS 272 RC outpatient 6.4 5.12 Cigna Commercial PPO 3.52 percent of total billed charges 3.52 5.44 55% of Billed Charges BANDAGE COBAN 4 X 5 YRDS 272 RC inpatient 6.4 3.2 IMA of Louisiana Commercial PPO 5.44 percent of total billed charges 3.2 5.44 Inpatient Reimbursement at 85% of Billed Charges BANDAGE COBAN 4 X 5 YRDS 272 RC outpatient 6.4 5.12 IMA of Louisiana Commercial PPO 5.44 percent of total billed charges 3.52 5.44 Reimbursement at 85% of billed charges BANDAGE COBAN 4 X 5 YRDS 272 RC outpatient 6.4 5.12 Aetna Commercial PPO 3.52 percent of total billed charges 3.52 5.44 55 of billed Charges CANNULA UNIV NF 5.5 MM X 70MM 272 RC inpatient 455 227.5 BCBS Louisiana PPO 227.5 percent of total billed charges 227.5 386.75 50% of Eligible Charges CANNULA UNIV NF 5.5 MM X 70MM 272 RC outpatient 455 364 BCBS Louisiana PPO 364 percent of total billed charges 250.25 386.75 80% of billed charge CANNULA UNIV NF 5.5 MM X 70MM 272 RC outpatient 455 364 Cigna Commercial PPO 250.25 percent of total billed charges 250.25 386.75 55% of Billed Charges CANNULA UNIV NF 5.5 MM X 70MM 272 RC inpatient 455 227.5 IMA of Louisiana Commercial PPO 386.75 percent of total billed charges 227.5 386.75 Inpatient Reimbursement at 85% of Billed Charges CANNULA UNIV NF 5.5 MM X 70MM 272 RC outpatient 455 364 IMA of Louisiana Commercial PPO 386.75 percent of total billed charges 250.25 386.75 Reimbursement at 85% of billed charges CANNULA UNIV NF 5.5 MM X 70MM 272 RC outpatient 455 364 Aetna Commercial PPO 250.25 percent of total billed charges 250.25 386.75 55 of billed Charges CEMENT MIXER STRYKER HI-VAC 272 RC inpatient 784.8 392.4 BCBS Louisiana PPO 392.4 percent of total billed charges 392.4 667.08 50% of Eligible Charges CEMENT MIXER STRYKER HI-VAC 272 RC outpatient 784.8 627.84 BCBS Louisiana PPO 627.84 percent of total billed charges 431.64 667.08 80% of billed charge CEMENT MIXER STRYKER HI-VAC 272 RC outpatient 784.8 627.84 Cigna Commercial PPO 431.64 percent of total billed charges 431.64 667.08 55% of Billed Charges CEMENT MIXER STRYKER HI-VAC 272 RC inpatient 784.8 392.4 IMA of Louisiana Commercial PPO 667.08 percent of total billed charges 392.4 667.08 Inpatient Reimbursement at 85% of Billed Charges CEMENT MIXER STRYKER HI-VAC 272 RC outpatient 784.8 627.84 IMA of Louisiana Commercial PPO 667.08 percent of total billed charges 431.64 667.08 Reimbursement at 85% of billed charges CEMENT MIXER STRYKER HI-VAC 272 RC outpatient 784.8 627.84 Aetna Commercial PPO 431.64 percent of total billed charges 431.64 667.08 55 of billed Charges SHOE POST-OP SMALL 270 RC inpatient 28.32 14.16 BCBS Louisiana PPO 14.16 percent of total billed charges 14.16 24.07 50% of Eligible Charges SHOE POST-OP SMALL 270 RC outpatient 28.32 22.66 BCBS Louisiana PPO 22.66 percent of total billed charges 15.58 24.07 80% of billed charge SHOE POST-OP SMALL 270 RC outpatient 28.32 22.66 Cigna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55% of Billed Charges SHOE POST-OP SMALL 270 RC inpatient 28.32 14.16 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 14.16 24.07 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP SMALL 270 RC outpatient 28.32 22.66 IMA of Louisiana Commercial PPO 24.07 percent of total billed charges 15.58 24.07 Reimbursement at 85% of billed charges SHOE POST-OP SMALL 270 RC outpatient 28.32 22.66 Aetna Commercial PPO 15.58 percent of total billed charges 15.58 24.07 55 of billed Charges RF CANNULA 20 GA 10CM 10MM 272 RC inpatient 450 225 BCBS Louisiana PPO 225 percent of total billed charges 225 382.5 50% of Eligible Charges RF CANNULA 20 GA 10CM 10MM 272 RC outpatient 450 360 BCBS Louisiana PPO 360 percent of total billed charges 247.5 382.5 80% of billed charge RF CANNULA 20 GA 10CM 10MM 272 RC outpatient 450 360 Cigna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55% of Billed Charges RF CANNULA 20 GA 10CM 10MM 272 RC inpatient 450 225 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 225 382.5 Inpatient Reimbursement at 85% of Billed Charges RF CANNULA 20 GA 10CM 10MM 272 RC outpatient 450 360 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 247.5 382.5 Reimbursement at 85% of billed charges RF CANNULA 20 GA 10CM 10MM 272 RC outpatient 450 360 Aetna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55 of billed Charges MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC inpatient 257.15 128.58 BCBS Louisiana PPO 128.58 percent of total billed charges 128.58 218.58 50% of Eligible Charges MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC outpatient 257.15 205.72 BCBS Louisiana PPO 205.72 percent of total billed charges 141.43 218.58 80% of billed charge MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC outpatient 257.15 205.72 Cigna Commercial PPO 141.43 percent of total billed charges 141.43 218.58 55% of Billed Charges MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC inpatient 257.15 128.58 IMA of Louisiana Commercial PPO 218.58 percent of total billed charges 128.58 218.58 Inpatient Reimbursement at 85% of Billed Charges MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC outpatient 257.15 205.72 IMA of Louisiana Commercial PPO 218.58 percent of total billed charges 141.43 218.58 Reimbursement at 85% of billed charges MASK OXY HIGH CONC 3-IN-1 W/TU 270 RC outpatient 257.15 205.72 Aetna Commercial PPO 141.43 percent of total billed charges 141.43 218.58 55 of billed Charges SLEEVE STERILE 272 RC inpatient 4.4 2.2 BCBS Louisiana PPO 2.2 percent of total billed charges 2.2 3.74 50% of Eligible Charges SLEEVE STERILE 272 RC outpatient 4.4 3.52 BCBS Louisiana PPO 3.52 percent of total billed charges 2.42 3.74 80% of billed charge SLEEVE STERILE 272 RC outpatient 4.4 3.52 Cigna Commercial PPO 2.42 percent of total billed charges 2.42 3.74 55% of Billed Charges SLEEVE STERILE 272 RC inpatient 4.4 2.2 IMA of Louisiana Commercial PPO 3.74 percent of total billed charges 2.2 3.74 Inpatient Reimbursement at 85% of Billed Charges SLEEVE STERILE 272 RC outpatient 4.4 3.52 IMA of Louisiana Commercial PPO 3.74 percent of total billed charges 2.42 3.74 Reimbursement at 85% of billed charges SLEEVE STERILE 272 RC outpatient 4.4 3.52 Aetna Commercial PPO 2.42 percent of total billed charges 2.42 3.74 55 of billed Charges SUTURE REMOVAL KIT 272 RC inpatient 5.04 2.52 BCBS Louisiana PPO 2.52 percent of total billed charges 2.52 4.28 50% of Eligible Charges SUTURE REMOVAL KIT 272 RC outpatient 5.04 4.03 BCBS Louisiana PPO 4.03 percent of total billed charges 2.77 4.28 80% of billed charge SUTURE REMOVAL KIT 272 RC outpatient 5.04 4.03 Cigna Commercial PPO 2.77 percent of total billed charges 2.77 4.28 55% of Billed Charges SUTURE REMOVAL KIT 272 RC inpatient 5.04 2.52 IMA of Louisiana Commercial PPO 4.28 percent of total billed charges 2.52 4.28 Inpatient Reimbursement at 85% of Billed Charges SUTURE REMOVAL KIT 272 RC outpatient 5.04 4.03 IMA of Louisiana Commercial PPO 4.28 percent of total billed charges 2.77 4.28 Reimbursement at 85% of billed charges SUTURE REMOVAL KIT 272 RC outpatient 5.04 4.03 Aetna Commercial PPO 2.77 percent of total billed charges 2.77 4.28 55 of billed Charges SYRINGE INSULIN .5CC 28G X .5 272 RC inpatient 41.12 20.56 BCBS Louisiana PPO 20.56 percent of total billed charges 20.56 34.95 50% of Eligible Charges SYRINGE INSULIN .5CC 28G X .5 272 RC outpatient 41.12 32.9 BCBS Louisiana PPO 32.9 percent of total billed charges 22.62 34.95 80% of billed charge SYRINGE INSULIN .5CC 28G X .5 272 RC outpatient 41.12 32.9 Cigna Commercial PPO 22.62 percent of total billed charges 22.62 34.95 55% of Billed Charges SYRINGE INSULIN .5CC 28G X .5 272 RC inpatient 41.12 20.56 IMA of Louisiana Commercial PPO 34.95 percent of total billed charges 20.56 34.95 Inpatient Reimbursement at 85% of Billed Charges SYRINGE INSULIN .5CC 28G X .5 272 RC outpatient 41.12 32.9 IMA of Louisiana Commercial PPO 34.95 percent of total billed charges 22.62 34.95 Reimbursement at 85% of billed charges SYRINGE INSULIN .5CC 28G X .5 272 RC outpatient 41.12 32.9 Aetna Commercial PPO 22.62 percent of total billed charges 22.62 34.95 55 of billed Charges MASK VENTURI DUAL DIAL 270 RC inpatient 5.44 2.72 BCBS Louisiana PPO 2.72 percent of total billed charges 2.72 4.62 50% of Eligible Charges MASK VENTURI DUAL DIAL 270 RC outpatient 5.44 4.35 BCBS Louisiana PPO 4.35 percent of total billed charges 2.99 4.62 80% of billed charge MASK VENTURI DUAL DIAL 270 RC outpatient 5.44 4.35 Cigna Commercial PPO 2.99 percent of total billed charges 2.99 4.62 55% of Billed Charges MASK VENTURI DUAL DIAL 270 RC inpatient 5.44 2.72 IMA of Louisiana Commercial PPO 4.62 percent of total billed charges 2.72 4.62 Inpatient Reimbursement at 85% of Billed Charges MASK VENTURI DUAL DIAL 270 RC outpatient 5.44 4.35 IMA of Louisiana Commercial PPO 4.62 percent of total billed charges 2.99 4.62 Reimbursement at 85% of billed charges MASK VENTURI DUAL DIAL 270 RC outpatient 5.44 4.35 Aetna Commercial PPO 2.99 percent of total billed charges 2.99 4.62 55 of billed Charges BLANKET WARMING LOWER BODY 270 RC inpatient 21.16 10.58 BCBS Louisiana PPO 10.58 percent of total billed charges 10.58 17.99 50% of Eligible Charges BLANKET WARMING LOWER BODY 270 RC outpatient 21.16 16.93 BCBS Louisiana PPO 16.93 percent of total billed charges 11.64 17.99 80% of billed charge BLANKET WARMING LOWER BODY 270 RC outpatient 21.16 16.93 Cigna Commercial PPO 11.64 percent of total billed charges 11.64 17.99 55% of Billed Charges BLANKET WARMING LOWER BODY 270 RC inpatient 21.16 10.58 IMA of Louisiana Commercial PPO 17.99 percent of total billed charges 10.58 17.99 Inpatient Reimbursement at 85% of Billed Charges BLANKET WARMING LOWER BODY 270 RC outpatient 21.16 16.93 IMA of Louisiana Commercial PPO 17.99 percent of total billed charges 11.64 17.99 Reimbursement at 85% of billed charges BLANKET WARMING LOWER BODY 270 RC outpatient 21.16 16.93 Aetna Commercial PPO 11.64 percent of total billed charges 11.64 17.99 55 of billed Charges SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC inpatient 547.44 273.72 BCBS Louisiana PPO 273.72 percent of total billed charges 273.72 465.32 50% of Eligible Charges SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC outpatient 547.44 437.95 BCBS Louisiana PPO 437.95 percent of total billed charges 301.09 465.32 80% of billed charge SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC outpatient 547.44 437.95 Cigna Commercial PPO 301.09 percent of total billed charges 301.09 465.32 55% of Billed Charges SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC inpatient 547.44 273.72 IMA of Louisiana Commercial PPO 465.32 percent of total billed charges 273.72 465.32 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC outpatient 547.44 437.95 IMA of Louisiana Commercial PPO 465.32 percent of total billed charges 301.09 465.32 Reimbursement at 85% of billed charges SUTURE STRATAFIX 1 PDO SXPD2B410 272 RC outpatient 547.44 437.95 Aetna Commercial PPO 301.09 percent of total billed charges 301.09 465.32 55 of billed Charges SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC inpatient 48.58 24.29 BCBS Louisiana PPO 24.29 percent of total billed charges 24.29 41.29 50% of Eligible Charges SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC outpatient 48.58 38.86 BCBS Louisiana PPO 38.86 percent of total billed charges 26.72 41.29 80% of billed charge SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC outpatient 48.58 38.86 Cigna Commercial PPO 26.72 percent of total billed charges 26.72 41.29 55% of Billed Charges SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC inpatient 48.58 24.29 IMA of Louisiana Commercial PPO 41.29 percent of total billed charges 24.29 41.29 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC outpatient 48.58 38.86 IMA of Louisiana Commercial PPO 41.29 percent of total billed charges 26.72 41.29 Reimbursement at 85% of billed charges SUTURE 0 ETHIBOND CT-1 CR CX21D 272 RC outpatient 48.58 38.86 Aetna Commercial PPO 26.72 percent of total billed charges 26.72 41.29 55 of billed Charges SUTURE 5-0 PROLENE RB-1 272 RC inpatient 25.92 12.96 BCBS Louisiana PPO 12.96 percent of total billed charges 12.96 22.03 50% of Eligible Charges SUTURE 5-0 PROLENE RB-1 272 RC outpatient 25.92 20.74 BCBS Louisiana PPO 20.74 percent of total billed charges 14.26 22.03 80% of billed charge SUTURE 5-0 PROLENE RB-1 272 RC outpatient 25.92 20.74 Cigna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55% of Billed Charges SUTURE 5-0 PROLENE RB-1 272 RC inpatient 25.92 12.96 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 12.96 22.03 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 PROLENE RB-1 272 RC outpatient 25.92 20.74 IMA of Louisiana Commercial PPO 22.03 percent of total billed charges 14.26 22.03 Reimbursement at 85% of billed charges SUTURE 5-0 PROLENE RB-1 272 RC outpatient 25.92 20.74 Aetna Commercial PPO 14.26 percent of total billed charges 14.26 22.03 55 of billed Charges SUTURE 4-0 PROLENE SH DB ARMED 272 RC inpatient 18.24 9.12 BCBS Louisiana PPO 9.12 percent of total billed charges 9.12 15.5 50% of Eligible Charges SUTURE 4-0 PROLENE SH DB ARMED 272 RC outpatient 18.24 14.59 BCBS Louisiana PPO 14.59 percent of total billed charges 10.03 15.5 80% of billed charge SUTURE 4-0 PROLENE SH DB ARMED 272 RC outpatient 18.24 14.59 Cigna Commercial PPO 10.03 percent of total billed charges 10.03 15.5 55% of Billed Charges SUTURE 4-0 PROLENE SH DB ARMED 272 RC inpatient 18.24 9.12 IMA of Louisiana Commercial PPO 15.5 percent of total billed charges 9.12 15.5 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 PROLENE SH DB ARMED 272 RC outpatient 18.24 14.59 IMA of Louisiana Commercial PPO 15.5 percent of total billed charges 10.03 15.5 Reimbursement at 85% of billed charges SUTURE 4-0 PROLENE SH DB ARMED 272 RC outpatient 18.24 14.59 Aetna Commercial PPO 10.03 percent of total billed charges 10.03 15.5 55 of billed Charges SUTURE 0 VICRYL CP J479H 272 RC inpatient 519.86 259.93 BCBS Louisiana PPO 259.93 percent of total billed charges 259.93 441.88 50% of Eligible Charges SUTURE 0 VICRYL CP J479H 272 RC outpatient 519.86 415.89 BCBS Louisiana PPO 415.89 percent of total billed charges 285.92 441.88 80% of billed charge SUTURE 0 VICRYL CP J479H 272 RC outpatient 519.86 415.89 Cigna Commercial PPO 285.92 percent of total billed charges 285.92 441.88 55% of Billed Charges SUTURE 0 VICRYL CP J479H 272 RC inpatient 519.86 259.93 IMA of Louisiana Commercial PPO 441.88 percent of total billed charges 259.93 441.88 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CP J479H 272 RC outpatient 519.86 415.89 IMA of Louisiana Commercial PPO 441.88 percent of total billed charges 285.92 441.88 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CP J479H 272 RC outpatient 519.86 415.89 Aetna Commercial PPO 285.92 percent of total billed charges 285.92 441.88 55 of billed Charges NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC inpatient 525 262.5 BCBS Louisiana PPO 262.5 percent of total billed charges 262.5 446.25 50% of Eligible Charges NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC outpatient 525 420 BCBS Louisiana PPO 420 percent of total billed charges 288.75 446.25 80% of billed charge NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC outpatient 525 420 Cigna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55% of Billed Charges NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC inpatient 525 262.5 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 262.5 446.25 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC outpatient 525 420 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 288.75 446.25 Reimbursement at 85% of billed charges NEEDLE SPINAL WHITACRE 22G X 3 1/2 272 RC outpatient 525 420 Aetna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55 of billed Charges CATHETER 12 FR LTX FREE 272 RC inpatient 15.52 7.76 BCBS Louisiana PPO 7.76 percent of total billed charges 7.76 13.19 50% of Eligible Charges CATHETER 12 FR LTX FREE 272 RC outpatient 15.52 12.42 BCBS Louisiana PPO 12.42 percent of total billed charges 8.54 13.19 80% of billed charge CATHETER 12 FR LTX FREE 272 RC outpatient 15.52 12.42 Cigna Commercial PPO 8.54 percent of total billed charges 8.54 13.19 55% of Billed Charges CATHETER 12 FR LTX FREE 272 RC inpatient 15.52 7.76 IMA of Louisiana Commercial PPO 13.19 percent of total billed charges 7.76 13.19 Inpatient Reimbursement at 85% of Billed Charges CATHETER 12 FR LTX FREE 272 RC outpatient 15.52 12.42 IMA of Louisiana Commercial PPO 13.19 percent of total billed charges 8.54 13.19 Reimbursement at 85% of billed charges CATHETER 12 FR LTX FREE 272 RC outpatient 15.52 12.42 Aetna Commercial PPO 8.54 percent of total billed charges 8.54 13.19 55 of billed Charges GLOVE LATEX FREE 6.5 272 RC inpatient 6.72 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 3.36 5.71 50% of Eligible Charges GLOVE LATEX FREE 6.5 272 RC outpatient 6.72 5.38 BCBS Louisiana PPO 5.38 percent of total billed charges 3.7 5.71 80% of billed charge GLOVE LATEX FREE 6.5 272 RC outpatient 6.72 5.38 Cigna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55% of Billed Charges GLOVE LATEX FREE 6.5 272 RC inpatient 6.72 3.36 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.36 5.71 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE 6.5 272 RC outpatient 6.72 5.38 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.7 5.71 Reimbursement at 85% of billed charges GLOVE LATEX FREE 6.5 272 RC outpatient 6.72 5.38 Aetna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55 of billed Charges GLOVE LATEX FREE SZ 8 272 RC inpatient 6.72 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 3.36 5.71 50% of Eligible Charges GLOVE LATEX FREE SZ 8 272 RC outpatient 6.72 5.38 BCBS Louisiana PPO 5.38 percent of total billed charges 3.7 5.71 80% of billed charge GLOVE LATEX FREE SZ 8 272 RC outpatient 6.72 5.38 Cigna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55% of Billed Charges GLOVE LATEX FREE SZ 8 272 RC inpatient 6.72 3.36 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.36 5.71 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 8 272 RC outpatient 6.72 5.38 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.7 5.71 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 8 272 RC outpatient 6.72 5.38 Aetna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55 of billed Charges I-STAT TEST CART. CHEM 8+ 270 RC inpatient 533.07 266.54 BCBS Louisiana PPO 266.54 percent of total billed charges 266.54 453.11 50% of Eligible Charges I-STAT TEST CART. CHEM 8+ 270 RC outpatient 533.07 426.46 BCBS Louisiana PPO 426.46 percent of total billed charges 293.19 453.11 80% of billed charge I-STAT TEST CART. CHEM 8+ 270 RC outpatient 533.07 426.46 Cigna Commercial PPO 293.19 percent of total billed charges 293.19 453.11 55% of Billed Charges I-STAT TEST CART. CHEM 8+ 270 RC inpatient 533.07 266.54 IMA of Louisiana Commercial PPO 453.11 percent of total billed charges 266.54 453.11 Inpatient Reimbursement at 85% of Billed Charges I-STAT TEST CART. CHEM 8+ 270 RC outpatient 533.07 426.46 IMA of Louisiana Commercial PPO 453.11 percent of total billed charges 293.19 453.11 Reimbursement at 85% of billed charges I-STAT TEST CART. CHEM 8+ 270 RC outpatient 533.07 426.46 Aetna Commercial PPO 293.19 percent of total billed charges 293.19 453.11 55 of billed Charges CANNULA CRYSTAL 5.75MM X 7 272 RC inpatient 437.5 218.75 BCBS Louisiana PPO 218.75 percent of total billed charges 218.75 371.88 50% of Eligible Charges CANNULA CRYSTAL 5.75MM X 7 272 RC outpatient 437.5 350 BCBS Louisiana PPO 350 percent of total billed charges 240.63 371.88 80% of billed charge CANNULA CRYSTAL 5.75MM X 7 272 RC outpatient 437.5 350 Cigna Commercial PPO 240.63 percent of total billed charges 240.63 371.88 55% of Billed Charges CANNULA CRYSTAL 5.75MM X 7 272 RC inpatient 437.5 218.75 IMA of Louisiana Commercial PPO 371.88 percent of total billed charges 218.75 371.88 Inpatient Reimbursement at 85% of Billed Charges CANNULA CRYSTAL 5.75MM X 7 272 RC outpatient 437.5 350 IMA of Louisiana Commercial PPO 371.88 percent of total billed charges 240.63 371.88 Reimbursement at 85% of billed charges CANNULA CRYSTAL 5.75MM X 7 272 RC outpatient 437.5 350 Aetna Commercial PPO 240.63 percent of total billed charges 240.63 371.88 55 of billed Charges SAW BLADE 2296-3-109S2 272 RC inpatient 155.75 77.88 BCBS Louisiana PPO 77.88 percent of total billed charges 77.88 132.39 50% of Eligible Charges SAW BLADE 2296-3-109S2 272 RC outpatient 155.75 124.6 BCBS Louisiana PPO 124.6 percent of total billed charges 85.66 132.39 80% of billed charge SAW BLADE 2296-3-109S2 272 RC outpatient 155.75 124.6 Cigna Commercial PPO 85.66 percent of total billed charges 85.66 132.39 55% of Billed Charges SAW BLADE 2296-3-109S2 272 RC inpatient 155.75 77.88 IMA of Louisiana Commercial PPO 132.39 percent of total billed charges 77.88 132.39 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2296-3-109S2 272 RC outpatient 155.75 124.6 IMA of Louisiana Commercial PPO 132.39 percent of total billed charges 85.66 132.39 Reimbursement at 85% of billed charges SAW BLADE 2296-3-109S2 272 RC outpatient 155.75 124.6 Aetna Commercial PPO 85.66 percent of total billed charges 85.66 132.39 55 of billed Charges SAW BLADE SP-525 272 RC inpatient 68 34 BCBS Louisiana PPO 34 percent of total billed charges 34 57.8 50% of Eligible Charges SAW BLADE SP-525 272 RC outpatient 68 54.4 BCBS Louisiana PPO 54.4 percent of total billed charges 37.4 57.8 80% of billed charge SAW BLADE SP-525 272 RC outpatient 68 54.4 Cigna Commercial PPO 37.4 percent of total billed charges 37.4 57.8 55% of Billed Charges SAW BLADE SP-525 272 RC inpatient 68 34 IMA of Louisiana Commercial PPO 57.8 percent of total billed charges 34 57.8 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE SP-525 272 RC outpatient 68 54.4 IMA of Louisiana Commercial PPO 57.8 percent of total billed charges 37.4 57.8 Reimbursement at 85% of billed charges SAW BLADE SP-525 272 RC outpatient 68 54.4 Aetna Commercial PPO 37.4 percent of total billed charges 37.4 57.8 55 of billed Charges SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 45MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC inpatient 81.76 40.88 BCBS Louisiana PPO 40.88 percent of total billed charges 40.88 69.5 50% of Eligible Charges SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC outpatient 81.76 65.41 BCBS Louisiana PPO 65.41 percent of total billed charges 30.25 69.5 80% of billed charge SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC outpatient 81.76 65.41 Cigna Commercial PPO 47.42 percent of total billed charges 30.25 69.5 58% of Billed Charges/$500 Threshold SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC inpatient 81.76 40.88 IMA of Louisiana Commercial PPO 69.5 percent of total billed charges 40.88 69.5 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC outpatient 81.76 65.41 IMA of Louisiana Commercial PPO 69.5 percent of total billed charges 30.25 69.5 Reimbursement at 85% of billed charges SCREW 4.5MM CORTEX 38MM C1713 HCPCS 278 RC outpatient 81.76 65.41 Aetna Commercial PPO 30.25 percent of total billed charges 30.25 69.5 37% Of Billed Charges 2000 SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 35MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 SUTURE 2 ETHIBOND OS-4 X519H 272 RC inpatient 10.6 5.3 BCBS Louisiana PPO 5.3 percent of total billed charges 5.3 9.01 50% of Eligible Charges SUTURE 2 ETHIBOND OS-4 X519H 272 RC outpatient 10.6 8.48 BCBS Louisiana PPO 8.48 percent of total billed charges 5.83 9.01 80% of billed charge SUTURE 2 ETHIBOND OS-4 X519H 272 RC outpatient 10.6 8.48 Cigna Commercial PPO 5.83 percent of total billed charges 5.83 9.01 55% of Billed Charges SUTURE 2 ETHIBOND OS-4 X519H 272 RC inpatient 10.6 5.3 IMA of Louisiana Commercial PPO 9.01 percent of total billed charges 5.3 9.01 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2 ETHIBOND OS-4 X519H 272 RC outpatient 10.6 8.48 IMA of Louisiana Commercial PPO 9.01 percent of total billed charges 5.83 9.01 Reimbursement at 85% of billed charges SUTURE 2 ETHIBOND OS-4 X519H 272 RC outpatient 10.6 8.48 Aetna Commercial PPO 5.83 percent of total billed charges 5.83 9.01 55 of billed Charges SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 33 51 80% of billed charge SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC outpatient 60 48 Cigna Commercial PPO 33 percent of total billed charges 33 51 55% of Billed Charges SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 33 51 Reimbursement at 85% of billed charges SHOULDER IMMOBILIZER - ACURIO/JONES 270 RC outpatient 60 48 Aetna Commercial PPO 33 percent of total billed charges 33 51 55 of billed Charges SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC inpatient 13.08 6.54 BCBS Louisiana PPO 6.54 percent of total billed charges 6.54 11.12 50% of Eligible Charges SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC outpatient 13.08 10.46 BCBS Louisiana PPO 10.46 percent of total billed charges 7.19 11.12 80% of billed charge SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC outpatient 13.08 10.46 Cigna Commercial PPO 7.19 percent of total billed charges 7.19 11.12 55% of Billed Charges SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC inpatient 13.08 6.54 IMA of Louisiana Commercial PPO 11.12 percent of total billed charges 6.54 11.12 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC outpatient 13.08 10.46 IMA of Louisiana Commercial PPO 11.12 percent of total billed charges 7.19 11.12 Reimbursement at 85% of billed charges SODIUM CHLOR .9% 1000ML IRR - BOTTLE 272 RC outpatient 13.08 10.46 Aetna Commercial PPO 7.19 percent of total billed charges 7.19 11.12 55 of billed Charges GLOVE SENSICARE SZ 9 272 RC inpatient 15 7.5 BCBS Louisiana PPO 7.5 percent of total billed charges 7.5 12.75 50% of Eligible Charges GLOVE SENSICARE SZ 9 272 RC outpatient 15 12 BCBS Louisiana PPO 12 percent of total billed charges 8.25 12.75 80% of billed charge GLOVE SENSICARE SZ 9 272 RC outpatient 15 12 Cigna Commercial PPO 8.25 percent of total billed charges 8.25 12.75 55% of Billed Charges GLOVE SENSICARE SZ 9 272 RC inpatient 15 7.5 IMA of Louisiana Commercial PPO 12.75 percent of total billed charges 7.5 12.75 Inpatient Reimbursement at 85% of Billed Charges GLOVE SENSICARE SZ 9 272 RC outpatient 15 12 IMA of Louisiana Commercial PPO 12.75 percent of total billed charges 8.25 12.75 Reimbursement at 85% of billed charges GLOVE SENSICARE SZ 9 272 RC outpatient 15 12 Aetna Commercial PPO 8.25 percent of total billed charges 8.25 12.75 55 of billed Charges CAST PADDING 6 STERILE 272 RC inpatient 389.65 194.83 BCBS Louisiana PPO 194.83 percent of total billed charges 194.83 331.2 50% of Eligible Charges CAST PADDING 6 STERILE 272 RC outpatient 389.65 311.72 BCBS Louisiana PPO 311.72 percent of total billed charges 214.31 331.2 80% of billed charge CAST PADDING 6 STERILE 272 RC outpatient 389.65 311.72 Cigna Commercial PPO 214.31 percent of total billed charges 214.31 331.2 55% of Billed Charges CAST PADDING 6 STERILE 272 RC inpatient 389.65 194.83 IMA of Louisiana Commercial PPO 331.2 percent of total billed charges 194.83 331.2 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 6 STERILE 272 RC outpatient 389.65 311.72 IMA of Louisiana Commercial PPO 331.2 percent of total billed charges 214.31 331.2 Reimbursement at 85% of billed charges CAST PADDING 6 STERILE 272 RC outpatient 389.65 311.72 Aetna Commercial PPO 214.31 percent of total billed charges 214.31 331.2 55 of billed Charges SUPER TURBOVAC 90 272 RC inpatient 4614.25 2307.13 BCBS Louisiana PPO 2307.13 percent of total billed charges 2307.13 3922.11 50% of Eligible Charges SUPER TURBOVAC 90 272 RC outpatient 4614.25 3691.4 BCBS Louisiana PPO 3691.4 percent of total billed charges 2537.84 3922.11 80% of billed charge SUPER TURBOVAC 90 272 RC outpatient 4614.25 3691.4 Cigna Commercial PPO 2537.84 percent of total billed charges 2537.84 3922.11 55% of Billed Charges SUPER TURBOVAC 90 272 RC inpatient 4614.25 2307.13 IMA of Louisiana Commercial PPO 3922.11 percent of total billed charges 2307.13 3922.11 Inpatient Reimbursement at 85% of Billed Charges SUPER TURBOVAC 90 272 RC outpatient 4614.25 3691.4 IMA of Louisiana Commercial PPO 3922.11 percent of total billed charges 2537.84 3922.11 Reimbursement at 85% of billed charges SUPER TURBOVAC 90 272 RC outpatient 4614.25 3691.4 Aetna Commercial PPO 2537.84 percent of total billed charges 2537.84 3922.11 55 of billed Charges SUTURE 0 VICRYL CT-1 CR J840D 272 RC inpatient 48.6 24.3 BCBS Louisiana PPO 24.3 percent of total billed charges 24.3 41.31 50% of Eligible Charges SUTURE 0 VICRYL CT-1 CR J840D 272 RC outpatient 48.6 38.88 BCBS Louisiana PPO 38.88 percent of total billed charges 26.73 41.31 80% of billed charge SUTURE 0 VICRYL CT-1 CR J840D 272 RC outpatient 48.6 38.88 Cigna Commercial PPO 26.73 percent of total billed charges 26.73 41.31 55% of Billed Charges SUTURE 0 VICRYL CT-1 CR J840D 272 RC inpatient 48.6 24.3 IMA of Louisiana Commercial PPO 41.31 percent of total billed charges 24.3 41.31 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CT-1 CR J840D 272 RC outpatient 48.6 38.88 IMA of Louisiana Commercial PPO 41.31 percent of total billed charges 26.73 41.31 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CT-1 CR J840D 272 RC outpatient 48.6 38.88 Aetna Commercial PPO 26.73 percent of total billed charges 26.73 41.31 55 of billed Charges PLANTAR ORTHOSIS BOOT LARGE 270 RC inpatient 210.46 105.23 BCBS Louisiana PPO 105.23 percent of total billed charges 105.23 178.89 50% of Eligible Charges PLANTAR ORTHOSIS BOOT LARGE 270 RC outpatient 210.46 168.37 BCBS Louisiana PPO 168.37 percent of total billed charges 115.75 178.89 80% of billed charge PLANTAR ORTHOSIS BOOT LARGE 270 RC outpatient 210.46 168.37 Cigna Commercial PPO 115.75 percent of total billed charges 115.75 178.89 55% of Billed Charges PLANTAR ORTHOSIS BOOT LARGE 270 RC inpatient 210.46 105.23 IMA of Louisiana Commercial PPO 178.89 percent of total billed charges 105.23 178.89 Inpatient Reimbursement at 85% of Billed Charges PLANTAR ORTHOSIS BOOT LARGE 270 RC outpatient 210.46 168.37 IMA of Louisiana Commercial PPO 178.89 percent of total billed charges 115.75 178.89 Reimbursement at 85% of billed charges PLANTAR ORTHOSIS BOOT LARGE 270 RC outpatient 210.46 168.37 Aetna Commercial PPO 115.75 percent of total billed charges 115.75 178.89 55 of billed Charges SUTURE 2-0 VICRYL X-1 J459H 272 RC inpatient 8.76 4.38 BCBS Louisiana PPO 4.38 percent of total billed charges 4.38 7.45 50% of Eligible Charges SUTURE 2-0 VICRYL X-1 J459H 272 RC outpatient 8.76 7.01 BCBS Louisiana PPO 7.01 percent of total billed charges 4.82 7.45 80% of billed charge SUTURE 2-0 VICRYL X-1 J459H 272 RC outpatient 8.76 7.01 Cigna Commercial PPO 4.82 percent of total billed charges 4.82 7.45 55% of Billed Charges SUTURE 2-0 VICRYL X-1 J459H 272 RC inpatient 8.76 4.38 IMA of Louisiana Commercial PPO 7.45 percent of total billed charges 4.38 7.45 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL X-1 J459H 272 RC outpatient 8.76 7.01 IMA of Louisiana Commercial PPO 7.45 percent of total billed charges 4.82 7.45 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL X-1 J459H 272 RC outpatient 8.76 7.01 Aetna Commercial PPO 4.82 percent of total billed charges 4.82 7.45 55 of billed Charges SUTURE 3-0 MERSILENE FS-1 R647H 272 RC inpatient 8.64 4.32 BCBS Louisiana PPO 4.32 percent of total billed charges 4.32 7.34 50% of Eligible Charges SUTURE 3-0 MERSILENE FS-1 R647H 272 RC outpatient 8.64 6.91 BCBS Louisiana PPO 6.91 percent of total billed charges 4.75 7.34 80% of billed charge SUTURE 3-0 MERSILENE FS-1 R647H 272 RC outpatient 8.64 6.91 Cigna Commercial PPO 4.75 percent of total billed charges 4.75 7.34 55% of Billed Charges SUTURE 3-0 MERSILENE FS-1 R647H 272 RC inpatient 8.64 4.32 IMA of Louisiana Commercial PPO 7.34 percent of total billed charges 4.32 7.34 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 MERSILENE FS-1 R647H 272 RC outpatient 8.64 6.91 IMA of Louisiana Commercial PPO 7.34 percent of total billed charges 4.75 7.34 Reimbursement at 85% of billed charges SUTURE 3-0 MERSILENE FS-1 R647H 272 RC outpatient 8.64 6.91 Aetna Commercial PPO 4.75 percent of total billed charges 4.75 7.34 55 of billed Charges STOCKING KNEE - XLG 270 RC inpatient 134.89 67.45 BCBS Louisiana PPO 67.45 percent of total billed charges 67.45 114.66 50% of Eligible Charges STOCKING KNEE - XLG 270 RC outpatient 134.89 107.91 BCBS Louisiana PPO 107.91 percent of total billed charges 74.19 114.66 80% of billed charge STOCKING KNEE - XLG 270 RC outpatient 134.89 107.91 Cigna Commercial PPO 74.19 percent of total billed charges 74.19 114.66 55% of Billed Charges STOCKING KNEE - XLG 270 RC inpatient 134.89 67.45 IMA of Louisiana Commercial PPO 114.66 percent of total billed charges 67.45 114.66 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - XLG 270 RC outpatient 134.89 107.91 IMA of Louisiana Commercial PPO 114.66 percent of total billed charges 74.19 114.66 Reimbursement at 85% of billed charges STOCKING KNEE - XLG 270 RC outpatient 134.89 107.91 Aetna Commercial PPO 74.19 percent of total billed charges 74.19 114.66 55 of billed Charges SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC inpatient 24.84 12.42 BCBS Louisiana PPO 12.42 percent of total billed charges 12.42 21.11 50% of Eligible Charges SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC outpatient 24.84 19.87 BCBS Louisiana PPO 19.87 percent of total billed charges 13.66 21.11 80% of billed charge SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC outpatient 24.84 19.87 Cigna Commercial PPO 13.66 percent of total billed charges 13.66 21.11 55% of Billed Charges SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC inpatient 24.84 12.42 IMA of Louisiana Commercial PPO 21.11 percent of total billed charges 12.42 21.11 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC outpatient 24.84 19.87 IMA of Louisiana Commercial PPO 21.11 percent of total billed charges 13.66 21.11 Reimbursement at 85% of billed charges SUTURE 4-0 VICRYL PS-2 J496G/J426H/J496H 272 RC outpatient 24.84 19.87 Aetna Commercial PPO 13.66 percent of total billed charges 13.66 21.11 55 of billed Charges SUTURE 5-0 ETHILON PS-2 1666H 272 RC inpatient 17 8.5 BCBS Louisiana PPO 8.5 percent of total billed charges 8.5 14.45 50% of Eligible Charges SUTURE 5-0 ETHILON PS-2 1666H 272 RC outpatient 17 13.6 BCBS Louisiana PPO 13.6 percent of total billed charges 9.35 14.45 80% of billed charge SUTURE 5-0 ETHILON PS-2 1666H 272 RC outpatient 17 13.6 Cigna Commercial PPO 9.35 percent of total billed charges 9.35 14.45 55% of Billed Charges SUTURE 5-0 ETHILON PS-2 1666H 272 RC inpatient 17 8.5 IMA of Louisiana Commercial PPO 14.45 percent of total billed charges 8.5 14.45 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 ETHILON PS-2 1666H 272 RC outpatient 17 13.6 IMA of Louisiana Commercial PPO 14.45 percent of total billed charges 9.35 14.45 Reimbursement at 85% of billed charges SUTURE 5-0 ETHILON PS-2 1666H 272 RC outpatient 17 13.6 Aetna Commercial PPO 9.35 percent of total billed charges 9.35 14.45 55 of billed Charges STOCKING KNEE - LARGE LONG 270 RC inpatient 134.47 67.24 BCBS Louisiana PPO 67.24 percent of total billed charges 67.24 114.3 50% of Eligible Charges STOCKING KNEE - LARGE LONG 270 RC outpatient 134.47 107.58 BCBS Louisiana PPO 107.58 percent of total billed charges 73.96 114.3 80% of billed charge STOCKING KNEE - LARGE LONG 270 RC outpatient 134.47 107.58 Cigna Commercial PPO 73.96 percent of total billed charges 73.96 114.3 55% of Billed Charges STOCKING KNEE - LARGE LONG 270 RC inpatient 134.47 67.24 IMA of Louisiana Commercial PPO 114.3 percent of total billed charges 67.24 114.3 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - LARGE LONG 270 RC outpatient 134.47 107.58 IMA of Louisiana Commercial PPO 114.3 percent of total billed charges 73.96 114.3 Reimbursement at 85% of billed charges STOCKING KNEE - LARGE LONG 270 RC outpatient 134.47 107.58 Aetna Commercial PPO 73.96 percent of total billed charges 73.96 114.3 55 of billed Charges SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 52MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 FIBERWIRE AR-7207 272 RC inpatient 615 307.5 BCBS Louisiana PPO 307.5 percent of total billed charges 307.5 522.75 50% of Eligible Charges FIBERWIRE AR-7207 272 RC outpatient 615 492 BCBS Louisiana PPO 492 percent of total billed charges 338.25 522.75 80% of billed charge FIBERWIRE AR-7207 272 RC outpatient 615 492 Cigna Commercial PPO 338.25 percent of total billed charges 338.25 522.75 55% of Billed Charges FIBERWIRE AR-7207 272 RC inpatient 615 307.5 IMA of Louisiana Commercial PPO 522.75 percent of total billed charges 307.5 522.75 Inpatient Reimbursement at 85% of Billed Charges FIBERWIRE AR-7207 272 RC outpatient 615 492 IMA of Louisiana Commercial PPO 522.75 percent of total billed charges 338.25 522.75 Reimbursement at 85% of billed charges FIBERWIRE AR-7207 272 RC outpatient 615 492 Aetna Commercial PPO 338.25 percent of total billed charges 338.25 522.75 55 of billed Charges DRAPE BILATERAL EXTREMITY 272 RC inpatient 38.11 19.06 BCBS Louisiana PPO 19.06 percent of total billed charges 19.06 32.39 50% of Eligible Charges DRAPE BILATERAL EXTREMITY 272 RC outpatient 38.11 30.49 BCBS Louisiana PPO 30.49 percent of total billed charges 20.96 32.39 80% of billed charge DRAPE BILATERAL EXTREMITY 272 RC outpatient 38.11 30.49 Cigna Commercial PPO 20.96 percent of total billed charges 20.96 32.39 55% of Billed Charges DRAPE BILATERAL EXTREMITY 272 RC inpatient 38.11 19.06 IMA of Louisiana Commercial PPO 32.39 percent of total billed charges 19.06 32.39 Inpatient Reimbursement at 85% of Billed Charges DRAPE BILATERAL EXTREMITY 272 RC outpatient 38.11 30.49 IMA of Louisiana Commercial PPO 32.39 percent of total billed charges 20.96 32.39 Reimbursement at 85% of billed charges DRAPE BILATERAL EXTREMITY 272 RC outpatient 38.11 30.49 Aetna Commercial PPO 20.96 percent of total billed charges 20.96 32.39 55 of billed Charges IV CATH 16G INTROCAN 272 RC inpatient 6.6 3.3 BCBS Louisiana PPO 3.3 percent of total billed charges 3.3 5.61 50% of Eligible Charges IV CATH 16G INTROCAN 272 RC outpatient 6.6 5.28 BCBS Louisiana PPO 5.28 percent of total billed charges 3.63 5.61 80% of billed charge IV CATH 16G INTROCAN 272 RC outpatient 6.6 5.28 Cigna Commercial PPO 3.63 percent of total billed charges 3.63 5.61 55% of Billed Charges IV CATH 16G INTROCAN 272 RC inpatient 6.6 3.3 IMA of Louisiana Commercial PPO 5.61 percent of total billed charges 3.3 5.61 Inpatient Reimbursement at 85% of Billed Charges IV CATH 16G INTROCAN 272 RC outpatient 6.6 5.28 IMA of Louisiana Commercial PPO 5.61 percent of total billed charges 3.63 5.61 Reimbursement at 85% of billed charges IV CATH 16G INTROCAN 272 RC outpatient 6.6 5.28 Aetna Commercial PPO 3.63 percent of total billed charges 3.63 5.61 55 of billed Charges IV EXT SET ULTRASITE BORE 8'' 272 RC inpatient 8.08 4.04 BCBS Louisiana PPO 4.04 percent of total billed charges 4.04 6.87 50% of Eligible Charges IV EXT SET ULTRASITE BORE 8'' 272 RC outpatient 8.08 6.46 BCBS Louisiana PPO 6.46 percent of total billed charges 4.44 6.87 80% of billed charge IV EXT SET ULTRASITE BORE 8'' 272 RC outpatient 8.08 6.46 Cigna Commercial PPO 4.44 percent of total billed charges 4.44 6.87 55% of Billed Charges IV EXT SET ULTRASITE BORE 8'' 272 RC inpatient 8.08 4.04 IMA of Louisiana Commercial PPO 6.87 percent of total billed charges 4.04 6.87 Inpatient Reimbursement at 85% of Billed Charges IV EXT SET ULTRASITE BORE 8'' 272 RC outpatient 8.08 6.46 IMA of Louisiana Commercial PPO 6.87 percent of total billed charges 4.44 6.87 Reimbursement at 85% of billed charges IV EXT SET ULTRASITE BORE 8'' 272 RC outpatient 8.08 6.46 Aetna Commercial PPO 4.44 percent of total billed charges 4.44 6.87 55 of billed Charges NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC inpatient 145.95 72.98 BCBS Louisiana PPO 72.98 percent of total billed charges 72.98 124.06 50% of Eligible Charges NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC outpatient 145.95 116.76 BCBS Louisiana PPO 116.76 percent of total billed charges 80.27 124.06 80% of billed charge NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC outpatient 145.95 116.76 Cigna Commercial PPO 80.27 percent of total billed charges 80.27 124.06 55% of Billed Charges NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC inpatient 145.95 72.98 IMA of Louisiana Commercial PPO 124.06 percent of total billed charges 72.98 124.06 Inpatient Reimbursement at 85% of Billed Charges NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC outpatient 145.95 116.76 IMA of Louisiana Commercial PPO 124.06 percent of total billed charges 80.27 124.06 Reimbursement at 85% of billed charges NEBULIZER MICRO-MIST SM VOL W/RESVR 270 RC outpatient 145.95 116.76 Aetna Commercial PPO 80.27 percent of total billed charges 80.27 124.06 55 of billed Charges NEBULIZER KIT STR WATER 350ML 270 RC inpatient 9.28 4.64 BCBS Louisiana PPO 4.64 percent of total billed charges 4.64 7.89 50% of Eligible Charges NEBULIZER KIT STR WATER 350ML 270 RC outpatient 9.28 7.42 BCBS Louisiana PPO 7.42 percent of total billed charges 5.1 7.89 80% of billed charge NEBULIZER KIT STR WATER 350ML 270 RC outpatient 9.28 7.42 Cigna Commercial PPO 5.1 percent of total billed charges 5.1 7.89 55% of Billed Charges NEBULIZER KIT STR WATER 350ML 270 RC inpatient 9.28 4.64 IMA of Louisiana Commercial PPO 7.89 percent of total billed charges 4.64 7.89 Inpatient Reimbursement at 85% of Billed Charges NEBULIZER KIT STR WATER 350ML 270 RC outpatient 9.28 7.42 IMA of Louisiana Commercial PPO 7.89 percent of total billed charges 5.1 7.89 Reimbursement at 85% of billed charges NEBULIZER KIT STR WATER 350ML 270 RC outpatient 9.28 7.42 Aetna Commercial PPO 5.1 percent of total billed charges 5.1 7.89 55 of billed Charges SAW BLADE SP-225 272 RC inpatient 38.08 19.04 BCBS Louisiana PPO 19.04 percent of total billed charges 19.04 32.37 50% of Eligible Charges SAW BLADE SP-225 272 RC outpatient 38.08 30.46 BCBS Louisiana PPO 30.46 percent of total billed charges 20.94 32.37 80% of billed charge SAW BLADE SP-225 272 RC outpatient 38.08 30.46 Cigna Commercial PPO 20.94 percent of total billed charges 20.94 32.37 55% of Billed Charges SAW BLADE SP-225 272 RC inpatient 38.08 19.04 IMA of Louisiana Commercial PPO 32.37 percent of total billed charges 19.04 32.37 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE SP-225 272 RC outpatient 38.08 30.46 IMA of Louisiana Commercial PPO 32.37 percent of total billed charges 20.94 32.37 Reimbursement at 85% of billed charges SAW BLADE SP-225 272 RC outpatient 38.08 30.46 Aetna Commercial PPO 20.94 percent of total billed charges 20.94 32.37 55 of billed Charges DENTURE CUP TEAL W/OPAQ LID 270 RC inpatient 190.05 95.03 BCBS Louisiana PPO 95.03 percent of total billed charges 95.03 161.54 50% of Eligible Charges DENTURE CUP TEAL W/OPAQ LID 270 RC outpatient 190.05 152.04 BCBS Louisiana PPO 152.04 percent of total billed charges 104.53 161.54 80% of billed charge DENTURE CUP TEAL W/OPAQ LID 270 RC outpatient 190.05 152.04 Cigna Commercial PPO 104.53 percent of total billed charges 104.53 161.54 55% of Billed Charges DENTURE CUP TEAL W/OPAQ LID 270 RC inpatient 190.05 95.03 IMA of Louisiana Commercial PPO 161.54 percent of total billed charges 95.03 161.54 Inpatient Reimbursement at 85% of Billed Charges DENTURE CUP TEAL W/OPAQ LID 270 RC outpatient 190.05 152.04 IMA of Louisiana Commercial PPO 161.54 percent of total billed charges 104.53 161.54 Reimbursement at 85% of billed charges DENTURE CUP TEAL W/OPAQ LID 270 RC outpatient 190.05 152.04 Aetna Commercial PPO 104.53 percent of total billed charges 104.53 161.54 55 of billed Charges TEGADERM DRESSING SMALL 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges TEGADERM DRESSING SMALL 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge TEGADERM DRESSING SMALL 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges TEGADERM DRESSING SMALL 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges TEGADERM DRESSING SMALL 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges TEGADERM DRESSING SMALL 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SAW BLADE 2108-140 272 RC inpatient 89.68 44.84 BCBS Louisiana PPO 44.84 percent of total billed charges 44.84 76.23 50% of Eligible Charges SAW BLADE 2108-140 272 RC outpatient 89.68 71.74 BCBS Louisiana PPO 71.74 percent of total billed charges 49.32 76.23 80% of billed charge SAW BLADE 2108-140 272 RC outpatient 89.68 71.74 Cigna Commercial PPO 49.32 percent of total billed charges 49.32 76.23 55% of Billed Charges SAW BLADE 2108-140 272 RC inpatient 89.68 44.84 IMA of Louisiana Commercial PPO 76.23 percent of total billed charges 44.84 76.23 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-140 272 RC outpatient 89.68 71.74 IMA of Louisiana Commercial PPO 76.23 percent of total billed charges 49.32 76.23 Reimbursement at 85% of billed charges SAW BLADE 2108-140 272 RC outpatient 89.68 71.74 Aetna Commercial PPO 49.32 percent of total billed charges 49.32 76.23 55 of billed Charges SLING ARM ENVELOPE MEDIUM 270 RC inpatient 12.08 6.04 BCBS Louisiana PPO 6.04 percent of total billed charges 6.04 10.27 50% of Eligible Charges SLING ARM ENVELOPE MEDIUM 270 RC outpatient 12.08 9.66 BCBS Louisiana PPO 9.66 percent of total billed charges 6.64 10.27 80% of billed charge SLING ARM ENVELOPE MEDIUM 270 RC outpatient 12.08 9.66 Cigna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55% of Billed Charges SLING ARM ENVELOPE MEDIUM 270 RC inpatient 12.08 6.04 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.04 10.27 Inpatient Reimbursement at 85% of Billed Charges SLING ARM ENVELOPE MEDIUM 270 RC outpatient 12.08 9.66 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.64 10.27 Reimbursement at 85% of billed charges SLING ARM ENVELOPE MEDIUM 270 RC outpatient 12.08 9.66 Aetna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55 of billed Charges SLING ARM ENVELOPE PEDIATRIC 270 RC inpatient 16.16 8.08 BCBS Louisiana PPO 8.08 percent of total billed charges 8.08 13.74 50% of Eligible Charges SLING ARM ENVELOPE PEDIATRIC 270 RC outpatient 16.16 12.93 BCBS Louisiana PPO 12.93 percent of total billed charges 8.89 13.74 80% of billed charge SLING ARM ENVELOPE PEDIATRIC 270 RC outpatient 16.16 12.93 Cigna Commercial PPO 8.89 percent of total billed charges 8.89 13.74 55% of Billed Charges SLING ARM ENVELOPE PEDIATRIC 270 RC inpatient 16.16 8.08 IMA of Louisiana Commercial PPO 13.74 percent of total billed charges 8.08 13.74 Inpatient Reimbursement at 85% of Billed Charges SLING ARM ENVELOPE PEDIATRIC 270 RC outpatient 16.16 12.93 IMA of Louisiana Commercial PPO 13.74 percent of total billed charges 8.89 13.74 Reimbursement at 85% of billed charges SLING ARM ENVELOPE PEDIATRIC 270 RC outpatient 16.16 12.93 Aetna Commercial PPO 8.89 percent of total billed charges 8.89 13.74 55 of billed Charges BANDAGE ESMARK 6 272 RC inpatient 25.09 12.55 BCBS Louisiana PPO 12.55 percent of total billed charges 12.55 21.33 50% of Eligible Charges BANDAGE ESMARK 6 272 RC outpatient 25.09 20.07 BCBS Louisiana PPO 20.07 percent of total billed charges 13.8 21.33 80% of billed charge BANDAGE ESMARK 6 272 RC outpatient 25.09 20.07 Cigna Commercial PPO 13.8 percent of total billed charges 13.8 21.33 55% of Billed Charges BANDAGE ESMARK 6 272 RC inpatient 25.09 12.55 IMA of Louisiana Commercial PPO 21.33 percent of total billed charges 12.55 21.33 Inpatient Reimbursement at 85% of Billed Charges BANDAGE ESMARK 6 272 RC outpatient 25.09 20.07 IMA of Louisiana Commercial PPO 21.33 percent of total billed charges 13.8 21.33 Reimbursement at 85% of billed charges BANDAGE ESMARK 6 272 RC outpatient 25.09 20.07 Aetna Commercial PPO 13.8 percent of total billed charges 13.8 21.33 55 of billed Charges SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 20MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 VENAFLOW STD CALF CUFF 270 RC inpatient 46.72 23.36 BCBS Louisiana PPO 23.36 percent of total billed charges 23.36 39.71 50% of Eligible Charges VENAFLOW STD CALF CUFF 270 RC outpatient 46.72 37.38 BCBS Louisiana PPO 37.38 percent of total billed charges 25.7 39.71 80% of billed charge VENAFLOW STD CALF CUFF 270 RC outpatient 46.72 37.38 Cigna Commercial PPO 25.7 percent of total billed charges 25.7 39.71 55% of Billed Charges VENAFLOW STD CALF CUFF 270 RC inpatient 46.72 23.36 IMA of Louisiana Commercial PPO 39.71 percent of total billed charges 23.36 39.71 Inpatient Reimbursement at 85% of Billed Charges VENAFLOW STD CALF CUFF 270 RC outpatient 46.72 37.38 IMA of Louisiana Commercial PPO 39.71 percent of total billed charges 25.7 39.71 Reimbursement at 85% of billed charges VENAFLOW STD CALF CUFF 270 RC outpatient 46.72 37.38 Aetna Commercial PPO 25.7 percent of total billed charges 25.7 39.71 55 of billed Charges LAMINECTOMY PACK 272 RC inpatient 581.3 290.65 BCBS Louisiana PPO 290.65 percent of total billed charges 290.65 494.11 50% of Eligible Charges LAMINECTOMY PACK 272 RC outpatient 581.3 465.04 BCBS Louisiana PPO 465.04 percent of total billed charges 319.72 494.11 80% of billed charge LAMINECTOMY PACK 272 RC outpatient 581.3 465.04 Cigna Commercial PPO 319.72 percent of total billed charges 319.72 494.11 55% of Billed Charges LAMINECTOMY PACK 272 RC inpatient 581.3 290.65 IMA of Louisiana Commercial PPO 494.11 percent of total billed charges 290.65 494.11 Inpatient Reimbursement at 85% of Billed Charges LAMINECTOMY PACK 272 RC outpatient 581.3 465.04 IMA of Louisiana Commercial PPO 494.11 percent of total billed charges 319.72 494.11 Reimbursement at 85% of billed charges LAMINECTOMY PACK 272 RC outpatient 581.3 465.04 Aetna Commercial PPO 319.72 percent of total billed charges 319.72 494.11 55 of billed Charges VENAFLOW CUFF FOOT 270 RC inpatient 67.16 33.58 BCBS Louisiana PPO 33.58 percent of total billed charges 33.58 57.09 50% of Eligible Charges VENAFLOW CUFF FOOT 270 RC outpatient 67.16 53.73 BCBS Louisiana PPO 53.73 percent of total billed charges 36.94 57.09 80% of billed charge VENAFLOW CUFF FOOT 270 RC outpatient 67.16 53.73 Cigna Commercial PPO 36.94 percent of total billed charges 36.94 57.09 55% of Billed Charges VENAFLOW CUFF FOOT 270 RC inpatient 67.16 33.58 IMA of Louisiana Commercial PPO 57.09 percent of total billed charges 33.58 57.09 Inpatient Reimbursement at 85% of Billed Charges VENAFLOW CUFF FOOT 270 RC outpatient 67.16 53.73 IMA of Louisiana Commercial PPO 57.09 percent of total billed charges 36.94 57.09 Reimbursement at 85% of billed charges VENAFLOW CUFF FOOT 270 RC outpatient 67.16 53.73 Aetna Commercial PPO 36.94 percent of total billed charges 36.94 57.09 55 of billed Charges PAD NAIL POLISH REMOVER 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges PAD NAIL POLISH REMOVER 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge PAD NAIL POLISH REMOVER 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges PAD NAIL POLISH REMOVER 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges PAD NAIL POLISH REMOVER 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges PAD NAIL POLISH REMOVER 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC inpatient 1625 812.5 BCBS Louisiana PPO 812.5 percent of total billed charges 812.5 1381.25 50% of Eligible Charges CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC outpatient 1625 1300 BCBS Louisiana PPO 1300 percent of total billed charges 601.25 1381.25 80% of billed charge CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC outpatient 1625 1300 Cigna Commercial PPO 942.5 percent of total billed charges 601.25 1381.25 58% of Billed Charges/$500 Threshold CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC inpatient 1625 812.5 IMA of Louisiana Commercial PPO 1381.25 percent of total billed charges 812.5 1381.25 Inpatient Reimbursement at 85% of Billed Charges CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC outpatient 1625 1300 IMA of Louisiana Commercial PPO 1381.25 percent of total billed charges 601.25 1381.25 Reimbursement at 85% of billed charges CEMENT #3 WRIGHT CMW 40G C1713 HCPCS 278 RC outpatient 1625 1300 Aetna Commercial PPO 601.25 percent of total billed charges 601.25 1381.25 37% Of Billed Charges 2000 MIAMI J COLLAR MEDIUM 270 RC inpatient 186.83 93.42 BCBS Louisiana PPO 93.42 percent of total billed charges 93.42 158.81 50% of Eligible Charges MIAMI J COLLAR MEDIUM 270 RC outpatient 186.83 149.46 BCBS Louisiana PPO 149.46 percent of total billed charges 102.76 158.81 80% of billed charge MIAMI J COLLAR MEDIUM 270 RC outpatient 186.83 149.46 Cigna Commercial PPO 102.76 percent of total billed charges 102.76 158.81 55% of Billed Charges MIAMI J COLLAR MEDIUM 270 RC inpatient 186.83 93.42 IMA of Louisiana Commercial PPO 158.81 percent of total billed charges 93.42 158.81 Inpatient Reimbursement at 85% of Billed Charges MIAMI J COLLAR MEDIUM 270 RC outpatient 186.83 149.46 IMA of Louisiana Commercial PPO 158.81 percent of total billed charges 102.76 158.81 Reimbursement at 85% of billed charges MIAMI J COLLAR MEDIUM 270 RC outpatient 186.83 149.46 Aetna Commercial PPO 102.76 percent of total billed charges 102.76 158.81 55 of billed Charges BUR 3.0MM ROUND K-64 272 RC inpatient 76 38 BCBS Louisiana PPO 38 percent of total billed charges 38 64.6 50% of Eligible Charges BUR 3.0MM ROUND K-64 272 RC outpatient 76 60.8 BCBS Louisiana PPO 60.8 percent of total billed charges 41.8 64.6 80% of billed charge BUR 3.0MM ROUND K-64 272 RC outpatient 76 60.8 Cigna Commercial PPO 41.8 percent of total billed charges 41.8 64.6 55% of Billed Charges BUR 3.0MM ROUND K-64 272 RC inpatient 76 38 IMA of Louisiana Commercial PPO 64.6 percent of total billed charges 38 64.6 Inpatient Reimbursement at 85% of Billed Charges BUR 3.0MM ROUND K-64 272 RC outpatient 76 60.8 IMA of Louisiana Commercial PPO 64.6 percent of total billed charges 41.8 64.6 Reimbursement at 85% of billed charges BUR 3.0MM ROUND K-64 272 RC outpatient 76 60.8 Aetna Commercial PPO 41.8 percent of total billed charges 41.8 64.6 55 of billed Charges HUBER INFUSION NEEDLE 272 RC inpatient 102.29 51.15 BCBS Louisiana PPO 51.15 percent of total billed charges 51.15 86.95 50% of Eligible Charges HUBER INFUSION NEEDLE 272 RC outpatient 102.29 81.83 BCBS Louisiana PPO 81.83 percent of total billed charges 56.26 86.95 80% of billed charge HUBER INFUSION NEEDLE 272 RC outpatient 102.29 81.83 Cigna Commercial PPO 56.26 percent of total billed charges 56.26 86.95 55% of Billed Charges HUBER INFUSION NEEDLE 272 RC inpatient 102.29 51.15 IMA of Louisiana Commercial PPO 86.95 percent of total billed charges 51.15 86.95 Inpatient Reimbursement at 85% of Billed Charges HUBER INFUSION NEEDLE 272 RC outpatient 102.29 81.83 IMA of Louisiana Commercial PPO 86.95 percent of total billed charges 56.26 86.95 Reimbursement at 85% of billed charges HUBER INFUSION NEEDLE 272 RC outpatient 102.29 81.83 Aetna Commercial PPO 56.26 percent of total billed charges 56.26 86.95 55 of billed Charges GLOVE LATEX FREE SZ 6 272 RC inpatient 6.72 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 3.36 5.71 50% of Eligible Charges GLOVE LATEX FREE SZ 6 272 RC outpatient 6.72 5.38 BCBS Louisiana PPO 5.38 percent of total billed charges 3.7 5.71 80% of billed charge GLOVE LATEX FREE SZ 6 272 RC outpatient 6.72 5.38 Cigna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55% of Billed Charges GLOVE LATEX FREE SZ 6 272 RC inpatient 6.72 3.36 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.36 5.71 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 6 272 RC outpatient 6.72 5.38 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.7 5.71 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 6 272 RC outpatient 6.72 5.38 Aetna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55 of billed Charges DRAPE LAPAROTOMY W/ ARM COVERS 272 RC inpatient 28 14 BCBS Louisiana PPO 14 percent of total billed charges 14 23.8 50% of Eligible Charges DRAPE LAPAROTOMY W/ ARM COVERS 272 RC outpatient 28 22.4 BCBS Louisiana PPO 22.4 percent of total billed charges 15.4 23.8 80% of billed charge DRAPE LAPAROTOMY W/ ARM COVERS 272 RC outpatient 28 22.4 Cigna Commercial PPO 15.4 percent of total billed charges 15.4 23.8 55% of Billed Charges DRAPE LAPAROTOMY W/ ARM COVERS 272 RC inpatient 28 14 IMA of Louisiana Commercial PPO 23.8 percent of total billed charges 14 23.8 Inpatient Reimbursement at 85% of Billed Charges DRAPE LAPAROTOMY W/ ARM COVERS 272 RC outpatient 28 22.4 IMA of Louisiana Commercial PPO 23.8 percent of total billed charges 15.4 23.8 Reimbursement at 85% of billed charges DRAPE LAPAROTOMY W/ ARM COVERS 272 RC outpatient 28 22.4 Aetna Commercial PPO 15.4 percent of total billed charges 15.4 23.8 55 of billed Charges SUTURE 0 SILK FSL 680H 272 RC inpatient 219.17 109.59 BCBS Louisiana PPO 109.59 percent of total billed charges 109.59 186.29 50% of Eligible Charges SUTURE 0 SILK FSL 680H 272 RC outpatient 219.17 175.34 BCBS Louisiana PPO 175.34 percent of total billed charges 120.54 186.29 80% of billed charge SUTURE 0 SILK FSL 680H 272 RC outpatient 219.17 175.34 Cigna Commercial PPO 120.54 percent of total billed charges 120.54 186.29 55% of Billed Charges SUTURE 0 SILK FSL 680H 272 RC inpatient 219.17 109.59 IMA of Louisiana Commercial PPO 186.29 percent of total billed charges 109.59 186.29 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 SILK FSL 680H 272 RC outpatient 219.17 175.34 IMA of Louisiana Commercial PPO 186.29 percent of total billed charges 120.54 186.29 Reimbursement at 85% of billed charges SUTURE 0 SILK FSL 680H 272 RC outpatient 219.17 175.34 Aetna Commercial PPO 120.54 percent of total billed charges 120.54 186.29 55 of billed Charges SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC inpatient 470.95 235.48 BCBS Louisiana PPO 235.48 percent of total billed charges 235.48 400.31 50% of Eligible Charges SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC outpatient 470.95 376.76 BCBS Louisiana PPO 376.76 percent of total billed charges 174.25 400.31 80% of billed charge SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Cigna Commercial PPO 273.15 percent of total billed charges 174.25 400.31 58% of Billed Charges/$500 Threshold SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC inpatient 470.95 235.48 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 235.48 400.31 Inpatient Reimbursement at 85% of Billed Charges SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC outpatient 470.95 376.76 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 174.25 400.31 Reimbursement at 85% of billed charges SCREW 7.3MM TI CANN. 16MM/35MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Aetna Commercial PPO 174.25 percent of total billed charges 174.25 400.31 37% Of Billed Charges 2000 DRAPE IOBAN SHORT 272 RC inpatient 21.74 10.87 BCBS Louisiana PPO 10.87 percent of total billed charges 10.87 18.48 50% of Eligible Charges DRAPE IOBAN SHORT 272 RC outpatient 21.74 17.39 BCBS Louisiana PPO 17.39 percent of total billed charges 11.96 18.48 80% of billed charge DRAPE IOBAN SHORT 272 RC outpatient 21.74 17.39 Cigna Commercial PPO 11.96 percent of total billed charges 11.96 18.48 55% of Billed Charges DRAPE IOBAN SHORT 272 RC inpatient 21.74 10.87 IMA of Louisiana Commercial PPO 18.48 percent of total billed charges 10.87 18.48 Inpatient Reimbursement at 85% of Billed Charges DRAPE IOBAN SHORT 272 RC outpatient 21.74 17.39 IMA of Louisiana Commercial PPO 18.48 percent of total billed charges 11.96 18.48 Reimbursement at 85% of billed charges DRAPE IOBAN SHORT 272 RC outpatient 21.74 17.39 Aetna Commercial PPO 11.96 percent of total billed charges 11.96 18.48 55 of billed Charges SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 48MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 ABDUCTION HIP PILLOW - LARGE 270 RC inpatient 64.76 32.38 BCBS Louisiana PPO 32.38 percent of total billed charges 32.38 55.05 50% of Eligible Charges ABDUCTION HIP PILLOW - LARGE 270 RC outpatient 64.76 51.81 BCBS Louisiana PPO 51.81 percent of total billed charges 35.62 55.05 80% of billed charge ABDUCTION HIP PILLOW - LARGE 270 RC outpatient 64.76 51.81 Cigna Commercial PPO 35.62 percent of total billed charges 35.62 55.05 55% of Billed Charges ABDUCTION HIP PILLOW - LARGE 270 RC inpatient 64.76 32.38 IMA of Louisiana Commercial PPO 55.05 percent of total billed charges 32.38 55.05 Inpatient Reimbursement at 85% of Billed Charges ABDUCTION HIP PILLOW - LARGE 270 RC outpatient 64.76 51.81 IMA of Louisiana Commercial PPO 55.05 percent of total billed charges 35.62 55.05 Reimbursement at 85% of billed charges ABDUCTION HIP PILLOW - LARGE 270 RC outpatient 64.76 51.81 Aetna Commercial PPO 35.62 percent of total billed charges 35.62 55.05 55 of billed Charges CANE CHROME REGULAR 270 RC inpatient 27.16 13.58 BCBS Louisiana PPO 13.58 percent of total billed charges 13.58 23.09 50% of Eligible Charges CANE CHROME REGULAR 270 RC outpatient 27.16 21.73 BCBS Louisiana PPO 21.73 percent of total billed charges 14.94 23.09 80% of billed charge CANE CHROME REGULAR 270 RC outpatient 27.16 21.73 Cigna Commercial PPO 14.94 percent of total billed charges 14.94 23.09 55% of Billed Charges CANE CHROME REGULAR 270 RC inpatient 27.16 13.58 IMA of Louisiana Commercial PPO 23.09 percent of total billed charges 13.58 23.09 Inpatient Reimbursement at 85% of Billed Charges CANE CHROME REGULAR 270 RC outpatient 27.16 21.73 IMA of Louisiana Commercial PPO 23.09 percent of total billed charges 14.94 23.09 Reimbursement at 85% of billed charges CANE CHROME REGULAR 270 RC outpatient 27.16 21.73 Aetna Commercial PPO 14.94 percent of total billed charges 14.94 23.09 55 of billed Charges TOURNIQUET REUSEABLE 18 270 RC inpatient 411.18 205.59 BCBS Louisiana PPO 205.59 percent of total billed charges 205.59 349.5 50% of Eligible Charges TOURNIQUET REUSEABLE 18 270 RC outpatient 411.18 328.94 BCBS Louisiana PPO 328.94 percent of total billed charges 226.15 349.5 80% of billed charge TOURNIQUET REUSEABLE 18 270 RC outpatient 411.18 328.94 Cigna Commercial PPO 226.15 percent of total billed charges 226.15 349.5 55% of Billed Charges TOURNIQUET REUSEABLE 18 270 RC inpatient 411.18 205.59 IMA of Louisiana Commercial PPO 349.5 percent of total billed charges 205.59 349.5 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET REUSEABLE 18 270 RC outpatient 411.18 328.94 IMA of Louisiana Commercial PPO 349.5 percent of total billed charges 226.15 349.5 Reimbursement at 85% of billed charges TOURNIQUET REUSEABLE 18 270 RC outpatient 411.18 328.94 Aetna Commercial PPO 226.15 percent of total billed charges 226.15 349.5 55 of billed Charges SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 42MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC inpatient 1747.88 873.94 BCBS Louisiana PPO 873.94 percent of total billed charges 873.94 1485.7 50% of Eligible Charges PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC outpatient 1747.88 1398.3 BCBS Louisiana PPO 1398.3 percent of total billed charges 646.72 1485.7 80% of billed charge PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC outpatient 1747.88 1398.3 Cigna Commercial PPO 1013.77 percent of total billed charges 646.72 1485.7 58% of Billed Charges/$500 Threshold PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC inpatient 1747.88 873.94 IMA of Louisiana Commercial PPO 1485.7 percent of total billed charges 873.94 1485.7 Inpatient Reimbursement at 85% of Billed Charges PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC outpatient 1747.88 1398.3 IMA of Louisiana Commercial PPO 1485.7 percent of total billed charges 646.72 1485.7 Reimbursement at 85% of billed charges PLATE 3.5MM LCP PROX HUMERUS 5HL C1713 HCPCS 278 RC outpatient 1747.88 1398.3 Aetna Commercial PPO 646.72 percent of total billed charges 646.72 1485.7 37% Of Billed Charges 2000 SUTURE 4-0 SURGILON 1910-32 272 RC inpatient 130.97 65.49 BCBS Louisiana PPO 65.49 percent of total billed charges 65.49 111.32 50% of Eligible Charges SUTURE 4-0 SURGILON 1910-32 272 RC outpatient 130.97 104.78 BCBS Louisiana PPO 104.78 percent of total billed charges 72.03 111.32 80% of billed charge SUTURE 4-0 SURGILON 1910-32 272 RC outpatient 130.97 104.78 Cigna Commercial PPO 72.03 percent of total billed charges 72.03 111.32 55% of Billed Charges SUTURE 4-0 SURGILON 1910-32 272 RC inpatient 130.97 65.49 IMA of Louisiana Commercial PPO 111.32 percent of total billed charges 65.49 111.32 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 SURGILON 1910-32 272 RC outpatient 130.97 104.78 IMA of Louisiana Commercial PPO 111.32 percent of total billed charges 72.03 111.32 Reimbursement at 85% of billed charges SUTURE 4-0 SURGILON 1910-32 272 RC outpatient 130.97 104.78 Aetna Commercial PPO 72.03 percent of total billed charges 72.03 111.32 55 of billed Charges CRUTCH BARIATRIC ADULT 270 RC inpatient 350.46 175.23 BCBS Louisiana PPO 175.23 percent of total billed charges 175.23 297.89 50% of Eligible Charges CRUTCH BARIATRIC ADULT 270 RC outpatient 350.46 280.37 BCBS Louisiana PPO 280.37 percent of total billed charges 192.75 297.89 80% of billed charge CRUTCH BARIATRIC ADULT 270 RC outpatient 350.46 280.37 Cigna Commercial PPO 192.75 percent of total billed charges 192.75 297.89 55% of Billed Charges CRUTCH BARIATRIC ADULT 270 RC inpatient 350.46 175.23 IMA of Louisiana Commercial PPO 297.89 percent of total billed charges 175.23 297.89 Inpatient Reimbursement at 85% of Billed Charges CRUTCH BARIATRIC ADULT 270 RC outpatient 350.46 280.37 IMA of Louisiana Commercial PPO 297.89 percent of total billed charges 192.75 297.89 Reimbursement at 85% of billed charges CRUTCH BARIATRIC ADULT 270 RC outpatient 350.46 280.37 Aetna Commercial PPO 192.75 percent of total billed charges 192.75 297.89 55 of billed Charges REFILL KIT - MEDTRONIC PAIN PUMP 272 RC inpatient 80 40 BCBS Louisiana PPO 40 percent of total billed charges 40 68 50% of Eligible Charges REFILL KIT - MEDTRONIC PAIN PUMP 272 RC outpatient 80 64 BCBS Louisiana PPO 64 percent of total billed charges 44 68 80% of billed charge REFILL KIT - MEDTRONIC PAIN PUMP 272 RC outpatient 80 64 Cigna Commercial PPO 44 percent of total billed charges 44 68 55% of Billed Charges REFILL KIT - MEDTRONIC PAIN PUMP 272 RC inpatient 80 40 IMA of Louisiana Commercial PPO 68 percent of total billed charges 40 68 Inpatient Reimbursement at 85% of Billed Charges REFILL KIT - MEDTRONIC PAIN PUMP 272 RC outpatient 80 64 IMA of Louisiana Commercial PPO 68 percent of total billed charges 44 68 Reimbursement at 85% of billed charges REFILL KIT - MEDTRONIC PAIN PUMP 272 RC outpatient 80 64 Aetna Commercial PPO 44 percent of total billed charges 44 68 55 of billed Charges SUTURE 2-0 TI-CRON GS-22 272 RC inpatient 269.89 134.95 BCBS Louisiana PPO 134.95 percent of total billed charges 134.95 229.41 50% of Eligible Charges SUTURE 2-0 TI-CRON GS-22 272 RC outpatient 269.89 215.91 BCBS Louisiana PPO 215.91 percent of total billed charges 148.44 229.41 80% of billed charge SUTURE 2-0 TI-CRON GS-22 272 RC outpatient 269.89 215.91 Cigna Commercial PPO 148.44 percent of total billed charges 148.44 229.41 55% of Billed Charges SUTURE 2-0 TI-CRON GS-22 272 RC inpatient 269.89 134.95 IMA of Louisiana Commercial PPO 229.41 percent of total billed charges 134.95 229.41 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 TI-CRON GS-22 272 RC outpatient 269.89 215.91 IMA of Louisiana Commercial PPO 229.41 percent of total billed charges 148.44 229.41 Reimbursement at 85% of billed charges SUTURE 2-0 TI-CRON GS-22 272 RC outpatient 269.89 215.91 Aetna Commercial PPO 148.44 percent of total billed charges 148.44 229.41 55 of billed Charges GLOVE ORTHO SZ 9 272 RC inpatient 194.81 97.41 BCBS Louisiana PPO 97.41 percent of total billed charges 97.41 165.59 50% of Eligible Charges GLOVE ORTHO SZ 9 272 RC outpatient 194.81 155.85 BCBS Louisiana PPO 155.85 percent of total billed charges 107.15 165.59 80% of billed charge GLOVE ORTHO SZ 9 272 RC outpatient 194.81 155.85 Cigna Commercial PPO 107.15 percent of total billed charges 107.15 165.59 55% of Billed Charges GLOVE ORTHO SZ 9 272 RC inpatient 194.81 97.41 IMA of Louisiana Commercial PPO 165.59 percent of total billed charges 97.41 165.59 Inpatient Reimbursement at 85% of Billed Charges GLOVE ORTHO SZ 9 272 RC outpatient 194.81 155.85 IMA of Louisiana Commercial PPO 165.59 percent of total billed charges 107.15 165.59 Reimbursement at 85% of billed charges GLOVE ORTHO SZ 9 272 RC outpatient 194.81 155.85 Aetna Commercial PPO 107.15 percent of total billed charges 107.15 165.59 55 of billed Charges MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC inpatient 4.61 2.31 BCBS Louisiana PPO 2.31 percent of total billed charges 2.31 3.92 50% of Eligible Charges MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC outpatient 4.61 3.69 BCBS Louisiana PPO 3.69 percent of total billed charges 2.54 3.92 80% of billed charge MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC outpatient 4.61 3.69 Cigna Commercial PPO 2.54 percent of total billed charges 2.54 3.92 55% of Billed Charges MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC inpatient 4.61 2.31 IMA of Louisiana Commercial PPO 3.92 percent of total billed charges 2.31 3.92 Inpatient Reimbursement at 85% of Billed Charges MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC outpatient 4.61 3.69 IMA of Louisiana Commercial PPO 3.92 percent of total billed charges 2.54 3.92 Reimbursement at 85% of billed charges MIDSTREAM(CLEAN) CATCH KIT W/CAS SOAP 272 RC outpatient 4.61 3.69 Aetna Commercial PPO 2.54 percent of total billed charges 2.54 3.92 55 of billed Charges BLOOD TUBING 272 RC inpatient 69.48 34.74 BCBS Louisiana PPO 34.74 percent of total billed charges 34.74 59.06 50% of Eligible Charges BLOOD TUBING 272 RC outpatient 69.48 55.58 BCBS Louisiana PPO 55.58 percent of total billed charges 38.21 59.06 80% of billed charge BLOOD TUBING 272 RC outpatient 69.48 55.58 Cigna Commercial PPO 38.21 percent of total billed charges 38.21 59.06 55% of Billed Charges BLOOD TUBING 272 RC inpatient 69.48 34.74 IMA of Louisiana Commercial PPO 59.06 percent of total billed charges 34.74 59.06 Inpatient Reimbursement at 85% of Billed Charges BLOOD TUBING 272 RC outpatient 69.48 55.58 IMA of Louisiana Commercial PPO 59.06 percent of total billed charges 38.21 59.06 Reimbursement at 85% of billed charges BLOOD TUBING 272 RC outpatient 69.48 55.58 Aetna Commercial PPO 38.21 percent of total billed charges 38.21 59.06 55 of billed Charges NEEDLE STELLATE 22G X 2 272 RC inpatient 624.46 312.23 BCBS Louisiana PPO 312.23 percent of total billed charges 312.23 530.79 50% of Eligible Charges NEEDLE STELLATE 22G X 2 272 RC outpatient 624.46 499.57 BCBS Louisiana PPO 499.57 percent of total billed charges 343.45 530.79 80% of billed charge NEEDLE STELLATE 22G X 2 272 RC outpatient 624.46 499.57 Cigna Commercial PPO 343.45 percent of total billed charges 343.45 530.79 55% of Billed Charges NEEDLE STELLATE 22G X 2 272 RC inpatient 624.46 312.23 IMA of Louisiana Commercial PPO 530.79 percent of total billed charges 312.23 530.79 Inpatient Reimbursement at 85% of Billed Charges NEEDLE STELLATE 22G X 2 272 RC outpatient 624.46 499.57 IMA of Louisiana Commercial PPO 530.79 percent of total billed charges 343.45 530.79 Reimbursement at 85% of billed charges NEEDLE STELLATE 22G X 2 272 RC outpatient 624.46 499.57 Aetna Commercial PPO 343.45 percent of total billed charges 343.45 530.79 55 of billed Charges OXYGEN TUBING - FLEXIBLE- EVA 270 RC inpatient 116.24 58.12 BCBS Louisiana PPO 58.12 percent of total billed charges 58.12 98.8 50% of Eligible Charges OXYGEN TUBING - FLEXIBLE- EVA 270 RC outpatient 116.24 92.99 BCBS Louisiana PPO 92.99 percent of total billed charges 63.93 98.8 80% of billed charge OXYGEN TUBING - FLEXIBLE- EVA 270 RC outpatient 116.24 92.99 Cigna Commercial PPO 63.93 percent of total billed charges 63.93 98.8 55% of Billed Charges OXYGEN TUBING - FLEXIBLE- EVA 270 RC inpatient 116.24 58.12 IMA of Louisiana Commercial PPO 98.8 percent of total billed charges 58.12 98.8 Inpatient Reimbursement at 85% of Billed Charges OXYGEN TUBING - FLEXIBLE- EVA 270 RC outpatient 116.24 92.99 IMA of Louisiana Commercial PPO 98.8 percent of total billed charges 63.93 98.8 Reimbursement at 85% of billed charges OXYGEN TUBING - FLEXIBLE- EVA 270 RC outpatient 116.24 92.99 Aetna Commercial PPO 63.93 percent of total billed charges 63.93 98.8 55 of billed Charges CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC inpatient 245.7 122.85 BCBS Louisiana PPO 122.85 percent of total billed charges 122.85 208.85 50% of Eligible Charges CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC outpatient 245.7 196.56 BCBS Louisiana PPO 196.56 percent of total billed charges 90.91 208.85 80% of billed charge CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC outpatient 245.7 196.56 Cigna Commercial PPO 142.51 percent of total billed charges 90.91 208.85 58% of Billed Charges/$500 Threshold CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC inpatient 245.7 122.85 IMA of Louisiana Commercial PPO 208.85 percent of total billed charges 122.85 208.85 Inpatient Reimbursement at 85% of Billed Charges CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC outpatient 245.7 196.56 IMA of Louisiana Commercial PPO 208.85 percent of total billed charges 90.91 208.85 Reimbursement at 85% of billed charges CERCLAGE WIRE WITH EYE 1.0/1.25MM--SYNTH C1713 HCPCS 278 RC outpatient 245.7 196.56 Aetna Commercial PPO 90.91 percent of total billed charges 90.91 208.85 37% Of Billed Charges 2000 GLOVE EXAM NITRL PF XLG 270 RC inpatient 67.96 33.98 BCBS Louisiana PPO 33.98 percent of total billed charges 33.98 57.77 50% of Eligible Charges GLOVE EXAM NITRL PF XLG 270 RC outpatient 67.96 54.37 BCBS Louisiana PPO 54.37 percent of total billed charges 37.38 57.77 80% of billed charge GLOVE EXAM NITRL PF XLG 270 RC outpatient 67.96 54.37 Cigna Commercial PPO 37.38 percent of total billed charges 37.38 57.77 55% of Billed Charges GLOVE EXAM NITRL PF XLG 270 RC inpatient 67.96 33.98 IMA of Louisiana Commercial PPO 57.77 percent of total billed charges 33.98 57.77 Inpatient Reimbursement at 85% of Billed Charges GLOVE EXAM NITRL PF XLG 270 RC outpatient 67.96 54.37 IMA of Louisiana Commercial PPO 57.77 percent of total billed charges 37.38 57.77 Reimbursement at 85% of billed charges GLOVE EXAM NITRL PF XLG 270 RC outpatient 67.96 54.37 Aetna Commercial PPO 37.38 percent of total billed charges 37.38 57.77 55 of billed Charges IMMOBILIZER UNIVERSAL KNEE 18 270 RC inpatient 48.4 24.2 BCBS Louisiana PPO 24.2 percent of total billed charges 24.2 41.14 50% of Eligible Charges IMMOBILIZER UNIVERSAL KNEE 18 270 RC outpatient 48.4 38.72 BCBS Louisiana PPO 38.72 percent of total billed charges 26.62 41.14 80% of billed charge IMMOBILIZER UNIVERSAL KNEE 18 270 RC outpatient 48.4 38.72 Cigna Commercial PPO 26.62 percent of total billed charges 26.62 41.14 55% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 18 270 RC inpatient 48.4 24.2 IMA of Louisiana Commercial PPO 41.14 percent of total billed charges 24.2 41.14 Inpatient Reimbursement at 85% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 18 270 RC outpatient 48.4 38.72 IMA of Louisiana Commercial PPO 41.14 percent of total billed charges 26.62 41.14 Reimbursement at 85% of billed charges IMMOBILIZER UNIVERSAL KNEE 18 270 RC outpatient 48.4 38.72 Aetna Commercial PPO 26.62 percent of total billed charges 26.62 41.14 55 of billed Charges GLOVE SENSICARE 8 1/2 272 RC inpatient 15.71 7.86 BCBS Louisiana PPO 7.86 percent of total billed charges 7.86 13.35 50% of Eligible Charges GLOVE SENSICARE 8 1/2 272 RC outpatient 15.71 12.57 BCBS Louisiana PPO 12.57 percent of total billed charges 8.64 13.35 80% of billed charge GLOVE SENSICARE 8 1/2 272 RC outpatient 15.71 12.57 Cigna Commercial PPO 8.64 percent of total billed charges 8.64 13.35 55% of Billed Charges GLOVE SENSICARE 8 1/2 272 RC inpatient 15.71 7.86 IMA of Louisiana Commercial PPO 13.35 percent of total billed charges 7.86 13.35 Inpatient Reimbursement at 85% of Billed Charges GLOVE SENSICARE 8 1/2 272 RC outpatient 15.71 12.57 IMA of Louisiana Commercial PPO 13.35 percent of total billed charges 8.64 13.35 Reimbursement at 85% of billed charges GLOVE SENSICARE 8 1/2 272 RC outpatient 15.71 12.57 Aetna Commercial PPO 8.64 percent of total billed charges 8.64 13.35 55 of billed Charges SUTURE 2-0 VICRYL CT-1 J945H 272 RC inpatient 6.84 3.42 BCBS Louisiana PPO 3.42 percent of total billed charges 3.42 5.81 50% of Eligible Charges SUTURE 2-0 VICRYL CT-1 J945H 272 RC outpatient 6.84 5.47 BCBS Louisiana PPO 5.47 percent of total billed charges 3.76 5.81 80% of billed charge SUTURE 2-0 VICRYL CT-1 J945H 272 RC outpatient 6.84 5.47 Cigna Commercial PPO 3.76 percent of total billed charges 3.76 5.81 55% of Billed Charges SUTURE 2-0 VICRYL CT-1 J945H 272 RC inpatient 6.84 3.42 IMA of Louisiana Commercial PPO 5.81 percent of total billed charges 3.42 5.81 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL CT-1 J945H 272 RC outpatient 6.84 5.47 IMA of Louisiana Commercial PPO 5.81 percent of total billed charges 3.76 5.81 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL CT-1 J945H 272 RC outpatient 6.84 5.47 Aetna Commercial PPO 3.76 percent of total billed charges 3.76 5.81 55 of billed Charges SUTURE 4-0 PROLENE RB-1 272 RC inpatient 419.85 209.93 BCBS Louisiana PPO 209.93 percent of total billed charges 209.93 356.87 50% of Eligible Charges SUTURE 4-0 PROLENE RB-1 272 RC outpatient 419.85 335.88 BCBS Louisiana PPO 335.88 percent of total billed charges 230.92 356.87 80% of billed charge SUTURE 4-0 PROLENE RB-1 272 RC outpatient 419.85 335.88 Cigna Commercial PPO 230.92 percent of total billed charges 230.92 356.87 55% of Billed Charges SUTURE 4-0 PROLENE RB-1 272 RC inpatient 419.85 209.93 IMA of Louisiana Commercial PPO 356.87 percent of total billed charges 209.93 356.87 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 PROLENE RB-1 272 RC outpatient 419.85 335.88 IMA of Louisiana Commercial PPO 356.87 percent of total billed charges 230.92 356.87 Reimbursement at 85% of billed charges SUTURE 4-0 PROLENE RB-1 272 RC outpatient 419.85 335.88 Aetna Commercial PPO 230.92 percent of total billed charges 230.92 356.87 55 of billed Charges CATHETER FOLEY 14 FR 272 RC inpatient 271.53 135.77 BCBS Louisiana PPO 135.77 percent of total billed charges 135.77 230.8 50% of Eligible Charges CATHETER FOLEY 14 FR 272 RC outpatient 271.53 217.22 BCBS Louisiana PPO 217.22 percent of total billed charges 149.34 230.8 80% of billed charge CATHETER FOLEY 14 FR 272 RC outpatient 271.53 217.22 Cigna Commercial PPO 149.34 percent of total billed charges 149.34 230.8 55% of Billed Charges CATHETER FOLEY 14 FR 272 RC inpatient 271.53 135.77 IMA of Louisiana Commercial PPO 230.8 percent of total billed charges 135.77 230.8 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY 14 FR 272 RC outpatient 271.53 217.22 IMA of Louisiana Commercial PPO 230.8 percent of total billed charges 149.34 230.8 Reimbursement at 85% of billed charges CATHETER FOLEY 14 FR 272 RC outpatient 271.53 217.22 Aetna Commercial PPO 149.34 percent of total billed charges 149.34 230.8 55 of billed Charges CATHETER COUDE LUB 16 FR 272 RC inpatient 62.48 31.24 BCBS Louisiana PPO 31.24 percent of total billed charges 31.24 53.11 50% of Eligible Charges CATHETER COUDE LUB 16 FR 272 RC outpatient 62.48 49.98 BCBS Louisiana PPO 49.98 percent of total billed charges 34.36 53.11 80% of billed charge CATHETER COUDE LUB 16 FR 272 RC outpatient 62.48 49.98 Cigna Commercial PPO 34.36 percent of total billed charges 34.36 53.11 55% of Billed Charges CATHETER COUDE LUB 16 FR 272 RC inpatient 62.48 31.24 IMA of Louisiana Commercial PPO 53.11 percent of total billed charges 31.24 53.11 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LUB 16 FR 272 RC outpatient 62.48 49.98 IMA of Louisiana Commercial PPO 53.11 percent of total billed charges 34.36 53.11 Reimbursement at 85% of billed charges CATHETER COUDE LUB 16 FR 272 RC outpatient 62.48 49.98 Aetna Commercial PPO 34.36 percent of total billed charges 34.36 53.11 55 of billed Charges BLADE CLIPPER ASSEMBLY 272 RC inpatient 10.78 5.39 BCBS Louisiana PPO 5.39 percent of total billed charges 5.39 9.16 50% of Eligible Charges BLADE CLIPPER ASSEMBLY 272 RC outpatient 10.78 8.62 BCBS Louisiana PPO 8.62 percent of total billed charges 5.93 9.16 80% of billed charge BLADE CLIPPER ASSEMBLY 272 RC outpatient 10.78 8.62 Cigna Commercial PPO 5.93 percent of total billed charges 5.93 9.16 55% of Billed Charges BLADE CLIPPER ASSEMBLY 272 RC inpatient 10.78 5.39 IMA of Louisiana Commercial PPO 9.16 percent of total billed charges 5.39 9.16 Inpatient Reimbursement at 85% of Billed Charges BLADE CLIPPER ASSEMBLY 272 RC outpatient 10.78 8.62 IMA of Louisiana Commercial PPO 9.16 percent of total billed charges 5.93 9.16 Reimbursement at 85% of billed charges BLADE CLIPPER ASSEMBLY 272 RC outpatient 10.78 8.62 Aetna Commercial PPO 5.93 percent of total billed charges 5.93 9.16 55 of billed Charges STERI 1010 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges STERI 1010 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge STERI 1010 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges STERI 1010 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges STERI 1010 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges STERI 1010 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges LMA SOFTSEAL SIZE 4 272 RC inpatient 27.89 13.95 BCBS Louisiana PPO 13.95 percent of total billed charges 13.95 23.71 50% of Eligible Charges LMA SOFTSEAL SIZE 4 272 RC outpatient 27.89 22.31 BCBS Louisiana PPO 22.31 percent of total billed charges 15.34 23.71 80% of billed charge LMA SOFTSEAL SIZE 4 272 RC outpatient 27.89 22.31 Cigna Commercial PPO 15.34 percent of total billed charges 15.34 23.71 55% of Billed Charges LMA SOFTSEAL SIZE 4 272 RC inpatient 27.89 13.95 IMA of Louisiana Commercial PPO 23.71 percent of total billed charges 13.95 23.71 Inpatient Reimbursement at 85% of Billed Charges LMA SOFTSEAL SIZE 4 272 RC outpatient 27.89 22.31 IMA of Louisiana Commercial PPO 23.71 percent of total billed charges 15.34 23.71 Reimbursement at 85% of billed charges LMA SOFTSEAL SIZE 4 272 RC outpatient 27.89 22.31 Aetna Commercial PPO 15.34 percent of total billed charges 15.34 23.71 55 of billed Charges SAW BLADE 277-96-275 272 RC inpatient 90.55 45.28 BCBS Louisiana PPO 45.28 percent of total billed charges 45.28 76.97 50% of Eligible Charges SAW BLADE 277-96-275 272 RC outpatient 90.55 72.44 BCBS Louisiana PPO 72.44 percent of total billed charges 49.8 76.97 80% of billed charge SAW BLADE 277-96-275 272 RC outpatient 90.55 72.44 Cigna Commercial PPO 49.8 percent of total billed charges 49.8 76.97 55% of Billed Charges SAW BLADE 277-96-275 272 RC inpatient 90.55 45.28 IMA of Louisiana Commercial PPO 76.97 percent of total billed charges 45.28 76.97 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 277-96-275 272 RC outpatient 90.55 72.44 IMA of Louisiana Commercial PPO 76.97 percent of total billed charges 49.8 76.97 Reimbursement at 85% of billed charges SAW BLADE 277-96-275 272 RC outpatient 90.55 72.44 Aetna Commercial PPO 49.8 percent of total billed charges 49.8 76.97 55 of billed Charges STERI STRIP 1/2 X 4 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges STERI STRIP 1/2 X 4 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge STERI STRIP 1/2 X 4 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges STERI STRIP 1/2 X 4 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges STERI STRIP 1/2 X 4 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges STERI STRIP 1/2 X 4 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SLING ARM ENVELOPE SM 270 RC inpatient 12.08 6.04 BCBS Louisiana PPO 6.04 percent of total billed charges 6.04 10.27 50% of Eligible Charges SLING ARM ENVELOPE SM 270 RC outpatient 12.08 9.66 BCBS Louisiana PPO 9.66 percent of total billed charges 6.64 10.27 80% of billed charge SLING ARM ENVELOPE SM 270 RC outpatient 12.08 9.66 Cigna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55% of Billed Charges SLING ARM ENVELOPE SM 270 RC inpatient 12.08 6.04 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.04 10.27 Inpatient Reimbursement at 85% of Billed Charges SLING ARM ENVELOPE SM 270 RC outpatient 12.08 9.66 IMA of Louisiana Commercial PPO 10.27 percent of total billed charges 6.64 10.27 Reimbursement at 85% of billed charges SLING ARM ENVELOPE SM 270 RC outpatient 12.08 9.66 Aetna Commercial PPO 6.64 percent of total billed charges 6.64 10.27 55 of billed Charges DRILL BIT 3.2MM CANN. - SYNTHES 272 RC inpatient 600.66 300.33 BCBS Louisiana PPO 300.33 percent of total billed charges 300.33 510.56 50% of Eligible Charges DRILL BIT 3.2MM CANN. - SYNTHES 272 RC outpatient 600.66 480.53 BCBS Louisiana PPO 480.53 percent of total billed charges 330.36 510.56 80% of billed charge DRILL BIT 3.2MM CANN. - SYNTHES 272 RC outpatient 600.66 480.53 Cigna Commercial PPO 330.36 percent of total billed charges 330.36 510.56 55% of Billed Charges DRILL BIT 3.2MM CANN. - SYNTHES 272 RC inpatient 600.66 300.33 IMA of Louisiana Commercial PPO 510.56 percent of total billed charges 300.33 510.56 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 3.2MM CANN. - SYNTHES 272 RC outpatient 600.66 480.53 IMA of Louisiana Commercial PPO 510.56 percent of total billed charges 330.36 510.56 Reimbursement at 85% of billed charges DRILL BIT 3.2MM CANN. - SYNTHES 272 RC outpatient 600.66 480.53 Aetna Commercial PPO 330.36 percent of total billed charges 330.36 510.56 55 of billed Charges SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 VENAFLOW XL CALF CUFF 270 RC inpatient 180.92 90.46 BCBS Louisiana PPO 90.46 percent of total billed charges 90.46 153.78 50% of Eligible Charges VENAFLOW XL CALF CUFF 270 RC outpatient 180.92 144.74 BCBS Louisiana PPO 144.74 percent of total billed charges 99.51 153.78 80% of billed charge VENAFLOW XL CALF CUFF 270 RC outpatient 180.92 144.74 Cigna Commercial PPO 99.51 percent of total billed charges 99.51 153.78 55% of Billed Charges VENAFLOW XL CALF CUFF 270 RC inpatient 180.92 90.46 IMA of Louisiana Commercial PPO 153.78 percent of total billed charges 90.46 153.78 Inpatient Reimbursement at 85% of Billed Charges VENAFLOW XL CALF CUFF 270 RC outpatient 180.92 144.74 IMA of Louisiana Commercial PPO 153.78 percent of total billed charges 99.51 153.78 Reimbursement at 85% of billed charges VENAFLOW XL CALF CUFF 270 RC outpatient 180.92 144.74 Aetna Commercial PPO 99.51 percent of total billed charges 99.51 153.78 55 of billed Charges BLADE ENDO CTR CAVANAUGH 272 RC inpatient 346.5 173.25 BCBS Louisiana PPO 173.25 percent of total billed charges 173.25 294.53 50% of Eligible Charges BLADE ENDO CTR CAVANAUGH 272 RC outpatient 346.5 277.2 BCBS Louisiana PPO 277.2 percent of total billed charges 190.58 294.53 80% of billed charge BLADE ENDO CTR CAVANAUGH 272 RC outpatient 346.5 277.2 Cigna Commercial PPO 190.58 percent of total billed charges 190.58 294.53 55% of Billed Charges BLADE ENDO CTR CAVANAUGH 272 RC inpatient 346.5 173.25 IMA of Louisiana Commercial PPO 294.53 percent of total billed charges 173.25 294.53 Inpatient Reimbursement at 85% of Billed Charges BLADE ENDO CTR CAVANAUGH 272 RC outpatient 346.5 277.2 IMA of Louisiana Commercial PPO 294.53 percent of total billed charges 190.58 294.53 Reimbursement at 85% of billed charges BLADE ENDO CTR CAVANAUGH 272 RC outpatient 346.5 277.2 Aetna Commercial PPO 190.58 percent of total billed charges 190.58 294.53 55 of billed Charges PCA TUBING 272 RC inpatient 29.76 14.88 BCBS Louisiana PPO 14.88 percent of total billed charges 14.88 25.3 50% of Eligible Charges PCA TUBING 272 RC outpatient 29.76 23.81 BCBS Louisiana PPO 23.81 percent of total billed charges 16.37 25.3 80% of billed charge PCA TUBING 272 RC outpatient 29.76 23.81 Cigna Commercial PPO 16.37 percent of total billed charges 16.37 25.3 55% of Billed Charges PCA TUBING 272 RC inpatient 29.76 14.88 IMA of Louisiana Commercial PPO 25.3 percent of total billed charges 14.88 25.3 Inpatient Reimbursement at 85% of Billed Charges PCA TUBING 272 RC outpatient 29.76 23.81 IMA of Louisiana Commercial PPO 25.3 percent of total billed charges 16.37 25.3 Reimbursement at 85% of billed charges PCA TUBING 272 RC outpatient 29.76 23.81 Aetna Commercial PPO 16.37 percent of total billed charges 16.37 25.3 55 of billed Charges TEGADERM DRESSING LARGE 6X8 272 RC inpatient 6.58 3.29 BCBS Louisiana PPO 3.29 percent of total billed charges 3.29 5.59 50% of Eligible Charges TEGADERM DRESSING LARGE 6X8 272 RC outpatient 6.58 5.26 BCBS Louisiana PPO 5.26 percent of total billed charges 3.62 5.59 80% of billed charge TEGADERM DRESSING LARGE 6X8 272 RC outpatient 6.58 5.26 Cigna Commercial PPO 3.62 percent of total billed charges 3.62 5.59 55% of Billed Charges TEGADERM DRESSING LARGE 6X8 272 RC inpatient 6.58 3.29 IMA of Louisiana Commercial PPO 5.59 percent of total billed charges 3.29 5.59 Inpatient Reimbursement at 85% of Billed Charges TEGADERM DRESSING LARGE 6X8 272 RC outpatient 6.58 5.26 IMA of Louisiana Commercial PPO 5.59 percent of total billed charges 3.62 5.59 Reimbursement at 85% of billed charges TEGADERM DRESSING LARGE 6X8 272 RC outpatient 6.58 5.26 Aetna Commercial PPO 3.62 percent of total billed charges 3.62 5.59 55 of billed Charges SUTURE 2-0 SILK TIE 30 A305H 272 RC inpatient 10.44 5.22 BCBS Louisiana PPO 5.22 percent of total billed charges 5.22 8.87 50% of Eligible Charges SUTURE 2-0 SILK TIE 30 A305H 272 RC outpatient 10.44 8.35 BCBS Louisiana PPO 8.35 percent of total billed charges 5.74 8.87 80% of billed charge SUTURE 2-0 SILK TIE 30 A305H 272 RC outpatient 10.44 8.35 Cigna Commercial PPO 5.74 percent of total billed charges 5.74 8.87 55% of Billed Charges SUTURE 2-0 SILK TIE 30 A305H 272 RC inpatient 10.44 5.22 IMA of Louisiana Commercial PPO 8.87 percent of total billed charges 5.22 8.87 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 SILK TIE 30 A305H 272 RC outpatient 10.44 8.35 IMA of Louisiana Commercial PPO 8.87 percent of total billed charges 5.74 8.87 Reimbursement at 85% of billed charges SUTURE 2-0 SILK TIE 30 A305H 272 RC outpatient 10.44 8.35 Aetna Commercial PPO 5.74 percent of total billed charges 5.74 8.87 55 of billed Charges PLEDGETS PTFE FELT 272 RC inpatient 534.38 267.19 BCBS Louisiana PPO 267.19 percent of total billed charges 267.19 454.22 50% of Eligible Charges PLEDGETS PTFE FELT 272 RC outpatient 534.38 427.5 BCBS Louisiana PPO 427.5 percent of total billed charges 293.91 454.22 80% of billed charge PLEDGETS PTFE FELT 272 RC outpatient 534.38 427.5 Cigna Commercial PPO 293.91 percent of total billed charges 293.91 454.22 55% of Billed Charges PLEDGETS PTFE FELT 272 RC inpatient 534.38 267.19 IMA of Louisiana Commercial PPO 454.22 percent of total billed charges 267.19 454.22 Inpatient Reimbursement at 85% of Billed Charges PLEDGETS PTFE FELT 272 RC outpatient 534.38 427.5 IMA of Louisiana Commercial PPO 454.22 percent of total billed charges 293.91 454.22 Reimbursement at 85% of billed charges PLEDGETS PTFE FELT 272 RC outpatient 534.38 427.5 Aetna Commercial PPO 293.91 percent of total billed charges 293.91 454.22 55 of billed Charges K-WIRE THREADED .035 272 RC inpatient 460.25 230.13 BCBS Louisiana PPO 230.13 percent of total billed charges 230.13 391.21 50% of Eligible Charges K-WIRE THREADED .035 272 RC outpatient 460.25 368.2 BCBS Louisiana PPO 368.2 percent of total billed charges 253.14 391.21 80% of billed charge K-WIRE THREADED .035 272 RC outpatient 460.25 368.2 Cigna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55% of Billed Charges K-WIRE THREADED .035 272 RC inpatient 460.25 230.13 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 230.13 391.21 Inpatient Reimbursement at 85% of Billed Charges K-WIRE THREADED .035 272 RC outpatient 460.25 368.2 IMA of Louisiana Commercial PPO 391.21 percent of total billed charges 253.14 391.21 Reimbursement at 85% of billed charges K-WIRE THREADED .035 272 RC outpatient 460.25 368.2 Aetna Commercial PPO 253.14 percent of total billed charges 253.14 391.21 55 of billed Charges SPONGE NEURO 1 X 1 272 RC inpatient 32.28 16.14 BCBS Louisiana PPO 16.14 percent of total billed charges 16.14 27.44 50% of Eligible Charges SPONGE NEURO 1 X 1 272 RC outpatient 32.28 25.82 BCBS Louisiana PPO 25.82 percent of total billed charges 17.75 27.44 80% of billed charge SPONGE NEURO 1 X 1 272 RC outpatient 32.28 25.82 Cigna Commercial PPO 17.75 percent of total billed charges 17.75 27.44 55% of Billed Charges SPONGE NEURO 1 X 1 272 RC inpatient 32.28 16.14 IMA of Louisiana Commercial PPO 27.44 percent of total billed charges 16.14 27.44 Inpatient Reimbursement at 85% of Billed Charges SPONGE NEURO 1 X 1 272 RC outpatient 32.28 25.82 IMA of Louisiana Commercial PPO 27.44 percent of total billed charges 17.75 27.44 Reimbursement at 85% of billed charges SPONGE NEURO 1 X 1 272 RC outpatient 32.28 25.82 Aetna Commercial PPO 17.75 percent of total billed charges 17.75 27.44 55 of billed Charges TOTAL KNEE PACK 272 RC inpatient 730.37 365.19 BCBS Louisiana PPO 365.19 percent of total billed charges 365.19 620.81 50% of Eligible Charges TOTAL KNEE PACK 272 RC outpatient 730.37 584.3 BCBS Louisiana PPO 584.3 percent of total billed charges 401.7 620.81 80% of billed charge TOTAL KNEE PACK 272 RC outpatient 730.37 584.3 Cigna Commercial PPO 401.7 percent of total billed charges 401.7 620.81 55% of Billed Charges TOTAL KNEE PACK 272 RC inpatient 730.37 365.19 IMA of Louisiana Commercial PPO 620.81 percent of total billed charges 365.19 620.81 Inpatient Reimbursement at 85% of Billed Charges TOTAL KNEE PACK 272 RC outpatient 730.37 584.3 IMA of Louisiana Commercial PPO 620.81 percent of total billed charges 401.7 620.81 Reimbursement at 85% of billed charges TOTAL KNEE PACK 272 RC outpatient 730.37 584.3 Aetna Commercial PPO 401.7 percent of total billed charges 401.7 620.81 55 of billed Charges DURAGEN DURAL GRAFT MATRIX 272 RC inpatient 576.76 288.38 BCBS Louisiana PPO 288.38 percent of total billed charges 288.38 490.25 50% of Eligible Charges DURAGEN DURAL GRAFT MATRIX 272 RC outpatient 576.76 461.41 BCBS Louisiana PPO 461.41 percent of total billed charges 317.22 490.25 80% of billed charge DURAGEN DURAL GRAFT MATRIX 272 RC outpatient 576.76 461.41 Cigna Commercial PPO 317.22 percent of total billed charges 317.22 490.25 55% of Billed Charges DURAGEN DURAL GRAFT MATRIX 272 RC inpatient 576.76 288.38 IMA of Louisiana Commercial PPO 490.25 percent of total billed charges 288.38 490.25 Inpatient Reimbursement at 85% of Billed Charges DURAGEN DURAL GRAFT MATRIX 272 RC outpatient 576.76 461.41 IMA of Louisiana Commercial PPO 490.25 percent of total billed charges 317.22 490.25 Reimbursement at 85% of billed charges DURAGEN DURAL GRAFT MATRIX 272 RC outpatient 576.76 461.41 Aetna Commercial PPO 317.22 percent of total billed charges 317.22 490.25 55 of billed Charges SURGICEL 272 RC inpatient 169.05 84.53 BCBS Louisiana PPO 84.53 percent of total billed charges 84.53 143.69 50% of Eligible Charges SURGICEL 272 RC outpatient 169.05 135.24 BCBS Louisiana PPO 135.24 percent of total billed charges 92.98 143.69 80% of billed charge SURGICEL 272 RC outpatient 169.05 135.24 Cigna Commercial PPO 92.98 percent of total billed charges 92.98 143.69 55% of Billed Charges SURGICEL 272 RC inpatient 169.05 84.53 IMA of Louisiana Commercial PPO 143.69 percent of total billed charges 84.53 143.69 Inpatient Reimbursement at 85% of Billed Charges SURGICEL 272 RC outpatient 169.05 135.24 IMA of Louisiana Commercial PPO 143.69 percent of total billed charges 92.98 143.69 Reimbursement at 85% of billed charges SURGICEL 272 RC outpatient 169.05 135.24 Aetna Commercial PPO 92.98 percent of total billed charges 92.98 143.69 55 of billed Charges GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC inpatient 15.28 7.64 BCBS Louisiana PPO 7.64 percent of total billed charges 7.64 12.99 50% of Eligible Charges GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC outpatient 15.28 12.22 BCBS Louisiana PPO 12.22 percent of total billed charges 8.4 12.99 80% of billed charge GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC outpatient 15.28 12.22 Cigna Commercial PPO 8.4 percent of total billed charges 8.4 12.99 55% of Billed Charges GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC inpatient 15.28 7.64 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 7.64 12.99 Inpatient Reimbursement at 85% of Billed Charges GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC outpatient 15.28 12.22 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 8.4 12.99 Reimbursement at 85% of billed charges GOWN NON-IMPERVIOUS XLG - YELL/AERO 272 RC outpatient 15.28 12.22 Aetna Commercial PPO 8.4 percent of total billed charges 8.4 12.99 55 of billed Charges PDS #0 CT-1 Z346H 272 RC inpatient 11.32 5.66 BCBS Louisiana PPO 5.66 percent of total billed charges 5.66 9.62 50% of Eligible Charges PDS #0 CT-1 Z346H 272 RC outpatient 11.32 9.06 BCBS Louisiana PPO 9.06 percent of total billed charges 6.23 9.62 80% of billed charge PDS #0 CT-1 Z346H 272 RC outpatient 11.32 9.06 Cigna Commercial PPO 6.23 percent of total billed charges 6.23 9.62 55% of Billed Charges PDS #0 CT-1 Z346H 272 RC inpatient 11.32 5.66 IMA of Louisiana Commercial PPO 9.62 percent of total billed charges 5.66 9.62 Inpatient Reimbursement at 85% of Billed Charges PDS #0 CT-1 Z346H 272 RC outpatient 11.32 9.06 IMA of Louisiana Commercial PPO 9.62 percent of total billed charges 6.23 9.62 Reimbursement at 85% of billed charges PDS #0 CT-1 Z346H 272 RC outpatient 11.32 9.06 Aetna Commercial PPO 6.23 percent of total billed charges 6.23 9.62 55 of billed Charges WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC inpatient 80 40 BCBS Louisiana PPO 40 percent of total billed charges 40 68 50% of Eligible Charges WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC outpatient 80 64 BCBS Louisiana PPO 64 percent of total billed charges 29.6 68 80% of billed charge WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC outpatient 80 64 Cigna Commercial PPO 46.4 percent of total billed charges 29.6 68 58% of Billed Charges/$500 Threshold WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC inpatient 80 40 IMA of Louisiana Commercial PPO 68 percent of total billed charges 40 68 Inpatient Reimbursement at 85% of Billed Charges WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC outpatient 80 64 IMA of Louisiana Commercial PPO 68 percent of total billed charges 29.6 68 Reimbursement at 85% of billed charges WASHER 219.99 - SYNTHES C1713 HCPCS 278 RC outpatient 80 64 Aetna Commercial PPO 29.6 percent of total billed charges 29.6 68 37% Of Billed Charges 2000 SUTURE 3-0 PDS PS-2 18 Z497G 272 RC inpatient 16.26 8.13 BCBS Louisiana PPO 8.13 percent of total billed charges 8.13 13.82 50% of Eligible Charges SUTURE 3-0 PDS PS-2 18 Z497G 272 RC outpatient 16.26 13.01 BCBS Louisiana PPO 13.01 percent of total billed charges 8.94 13.82 80% of billed charge SUTURE 3-0 PDS PS-2 18 Z497G 272 RC outpatient 16.26 13.01 Cigna Commercial PPO 8.94 percent of total billed charges 8.94 13.82 55% of Billed Charges SUTURE 3-0 PDS PS-2 18 Z497G 272 RC inpatient 16.26 8.13 IMA of Louisiana Commercial PPO 13.82 percent of total billed charges 8.13 13.82 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 PDS PS-2 18 Z497G 272 RC outpatient 16.26 13.01 IMA of Louisiana Commercial PPO 13.82 percent of total billed charges 8.94 13.82 Reimbursement at 85% of billed charges SUTURE 3-0 PDS PS-2 18 Z497G 272 RC outpatient 16.26 13.01 Aetna Commercial PPO 8.94 percent of total billed charges 8.94 13.82 55 of billed Charges PILLOW BLUE FACE - OSI 270 RC inpatient 389.73 194.87 BCBS Louisiana PPO 194.87 percent of total billed charges 194.87 331.27 50% of Eligible Charges PILLOW BLUE FACE - OSI 270 RC outpatient 389.73 311.78 BCBS Louisiana PPO 311.78 percent of total billed charges 214.35 331.27 80% of billed charge PILLOW BLUE FACE - OSI 270 RC outpatient 389.73 311.78 Cigna Commercial PPO 214.35 percent of total billed charges 214.35 331.27 55% of Billed Charges PILLOW BLUE FACE - OSI 270 RC inpatient 389.73 194.87 IMA of Louisiana Commercial PPO 331.27 percent of total billed charges 194.87 331.27 Inpatient Reimbursement at 85% of Billed Charges PILLOW BLUE FACE - OSI 270 RC outpatient 389.73 311.78 IMA of Louisiana Commercial PPO 331.27 percent of total billed charges 214.35 331.27 Reimbursement at 85% of billed charges PILLOW BLUE FACE - OSI 270 RC outpatient 389.73 311.78 Aetna Commercial PPO 214.35 percent of total billed charges 214.35 331.27 55 of billed Charges NEEDLE SPINAL 22G X 2 1/2 272 RC inpatient 203.77 101.89 BCBS Louisiana PPO 101.89 percent of total billed charges 101.89 173.2 50% of Eligible Charges NEEDLE SPINAL 22G X 2 1/2 272 RC outpatient 203.77 163.02 BCBS Louisiana PPO 163.02 percent of total billed charges 112.07 173.2 80% of billed charge NEEDLE SPINAL 22G X 2 1/2 272 RC outpatient 203.77 163.02 Cigna Commercial PPO 112.07 percent of total billed charges 112.07 173.2 55% of Billed Charges NEEDLE SPINAL 22G X 2 1/2 272 RC inpatient 203.77 101.89 IMA of Louisiana Commercial PPO 173.2 percent of total billed charges 101.89 173.2 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 22G X 2 1/2 272 RC outpatient 203.77 163.02 IMA of Louisiana Commercial PPO 173.2 percent of total billed charges 112.07 173.2 Reimbursement at 85% of billed charges NEEDLE SPINAL 22G X 2 1/2 272 RC outpatient 203.77 163.02 Aetna Commercial PPO 112.07 percent of total billed charges 112.07 173.2 55 of billed Charges NEEDLE SPINAL 25G X 3 1/2 272 RC inpatient 10.72 5.36 BCBS Louisiana PPO 5.36 percent of total billed charges 5.36 9.11 50% of Eligible Charges NEEDLE SPINAL 25G X 3 1/2 272 RC outpatient 10.72 8.58 BCBS Louisiana PPO 8.58 percent of total billed charges 5.9 9.11 80% of billed charge NEEDLE SPINAL 25G X 3 1/2 272 RC outpatient 10.72 8.58 Cigna Commercial PPO 5.9 percent of total billed charges 5.9 9.11 55% of Billed Charges NEEDLE SPINAL 25G X 3 1/2 272 RC inpatient 10.72 5.36 IMA of Louisiana Commercial PPO 9.11 percent of total billed charges 5.36 9.11 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 25G X 3 1/2 272 RC outpatient 10.72 8.58 IMA of Louisiana Commercial PPO 9.11 percent of total billed charges 5.9 9.11 Reimbursement at 85% of billed charges NEEDLE SPINAL 25G X 3 1/2 272 RC outpatient 10.72 8.58 Aetna Commercial PPO 5.9 percent of total billed charges 5.9 9.11 55 of billed Charges NEEDLE TUOHY 18G X 3 1/2 272 RC inpatient 40.38 20.19 BCBS Louisiana PPO 20.19 percent of total billed charges 20.19 34.32 50% of Eligible Charges NEEDLE TUOHY 18G X 3 1/2 272 RC outpatient 40.38 32.3 BCBS Louisiana PPO 32.3 percent of total billed charges 22.21 34.32 80% of billed charge NEEDLE TUOHY 18G X 3 1/2 272 RC outpatient 40.38 32.3 Cigna Commercial PPO 22.21 percent of total billed charges 22.21 34.32 55% of Billed Charges NEEDLE TUOHY 18G X 3 1/2 272 RC inpatient 40.38 20.19 IMA of Louisiana Commercial PPO 34.32 percent of total billed charges 20.19 34.32 Inpatient Reimbursement at 85% of Billed Charges NEEDLE TUOHY 18G X 3 1/2 272 RC outpatient 40.38 32.3 IMA of Louisiana Commercial PPO 34.32 percent of total billed charges 22.21 34.32 Reimbursement at 85% of billed charges NEEDLE TUOHY 18G X 3 1/2 272 RC outpatient 40.38 32.3 Aetna Commercial PPO 22.21 percent of total billed charges 22.21 34.32 55 of billed Charges BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC inpatient 8.72 4.36 BCBS Louisiana PPO 4.36 percent of total billed charges 4.36 7.41 50% of Eligible Charges BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC outpatient 8.72 6.98 BCBS Louisiana PPO 6.98 percent of total billed charges 4.8 7.41 80% of billed charge BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC outpatient 8.72 6.98 Cigna Commercial PPO 4.8 percent of total billed charges 4.8 7.41 55% of Billed Charges BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC inpatient 8.72 4.36 IMA of Louisiana Commercial PPO 7.41 percent of total billed charges 4.36 7.41 Inpatient Reimbursement at 85% of Billed Charges BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC outpatient 8.72 6.98 IMA of Louisiana Commercial PPO 7.41 percent of total billed charges 4.8 7.41 Reimbursement at 85% of billed charges BUTTERFLY NEEDLE 21G COLLECTION SET 272 RC outpatient 8.72 6.98 Aetna Commercial PPO 4.8 percent of total billed charges 4.8 7.41 55 of billed Charges ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC inpatient 540 270 BCBS Louisiana PPO 270 percent of total billed charges 270 459 50% of Eligible Charges ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 BCBS Louisiana PPO 432 percent of total billed charges 297 459 80% of billed charge ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 Cigna Commercial PPO 297 percent of total billed charges 297 459 55% of Billed Charges ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC inpatient 540 270 IMA of Louisiana Commercial PPO 459 percent of total billed charges 270 459 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 IMA of Louisiana Commercial PPO 459 percent of total billed charges 297 459 Reimbursement at 85% of billed charges ARTHROSCOPY 4.0MM ACROMIOBLASTER - S&N 272 RC outpatient 540 432 Aetna Commercial PPO 297 percent of total billed charges 297 459 55 of billed Charges MAYFIELD DISP SKULL PIN 272 RC inpatient 677.9 338.95 BCBS Louisiana PPO 338.95 percent of total billed charges 338.95 576.22 50% of Eligible Charges MAYFIELD DISP SKULL PIN 272 RC outpatient 677.9 542.32 BCBS Louisiana PPO 542.32 percent of total billed charges 372.85 576.22 80% of billed charge MAYFIELD DISP SKULL PIN 272 RC outpatient 677.9 542.32 Cigna Commercial PPO 372.85 percent of total billed charges 372.85 576.22 55% of Billed Charges MAYFIELD DISP SKULL PIN 272 RC inpatient 677.9 338.95 IMA of Louisiana Commercial PPO 576.22 percent of total billed charges 338.95 576.22 Inpatient Reimbursement at 85% of Billed Charges MAYFIELD DISP SKULL PIN 272 RC outpatient 677.9 542.32 IMA of Louisiana Commercial PPO 576.22 percent of total billed charges 372.85 576.22 Reimbursement at 85% of billed charges MAYFIELD DISP SKULL PIN 272 RC outpatient 677.9 542.32 Aetna Commercial PPO 372.85 percent of total billed charges 372.85 576.22 55 of billed Charges PALL FILTER 270 RC inpatient 495 247.5 BCBS Louisiana PPO 247.5 percent of total billed charges 247.5 420.75 50% of Eligible Charges PALL FILTER 270 RC outpatient 495 396 BCBS Louisiana PPO 396 percent of total billed charges 272.25 420.75 80% of billed charge PALL FILTER 270 RC outpatient 495 396 Cigna Commercial PPO 272.25 percent of total billed charges 272.25 420.75 55% of Billed Charges PALL FILTER 270 RC inpatient 495 247.5 IMA of Louisiana Commercial PPO 420.75 percent of total billed charges 247.5 420.75 Inpatient Reimbursement at 85% of Billed Charges PALL FILTER 270 RC outpatient 495 396 IMA of Louisiana Commercial PPO 420.75 percent of total billed charges 272.25 420.75 Reimbursement at 85% of billed charges PALL FILTER 270 RC outpatient 495 396 Aetna Commercial PPO 272.25 percent of total billed charges 272.25 420.75 55 of billed Charges STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC inpatient 134.44 67.22 BCBS Louisiana PPO 67.22 percent of total billed charges 67.22 114.27 50% of Eligible Charges STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC outpatient 134.44 107.55 BCBS Louisiana PPO 107.55 percent of total billed charges 73.94 114.27 80% of billed charge STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC outpatient 134.44 107.55 Cigna Commercial PPO 73.94 percent of total billed charges 73.94 114.27 55% of Billed Charges STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC inpatient 134.44 67.22 IMA of Louisiana Commercial PPO 114.27 percent of total billed charges 67.22 114.27 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC outpatient 134.44 107.55 IMA of Louisiana Commercial PPO 114.27 percent of total billed charges 73.94 114.27 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM THIGH 2XL 270 RC outpatient 134.44 107.55 Aetna Commercial PPO 73.94 percent of total billed charges 73.94 114.27 55 of billed Charges TOURNIQUET 18 DISPOSABLE 272 RC inpatient 220.89 110.45 BCBS Louisiana PPO 110.45 percent of total billed charges 110.45 187.76 50% of Eligible Charges TOURNIQUET 18 DISPOSABLE 272 RC outpatient 220.89 176.71 BCBS Louisiana PPO 176.71 percent of total billed charges 121.49 187.76 80% of billed charge TOURNIQUET 18 DISPOSABLE 272 RC outpatient 220.89 176.71 Cigna Commercial PPO 121.49 percent of total billed charges 121.49 187.76 55% of Billed Charges TOURNIQUET 18 DISPOSABLE 272 RC inpatient 220.89 110.45 IMA of Louisiana Commercial PPO 187.76 percent of total billed charges 110.45 187.76 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 18 DISPOSABLE 272 RC outpatient 220.89 176.71 IMA of Louisiana Commercial PPO 187.76 percent of total billed charges 121.49 187.76 Reimbursement at 85% of billed charges TOURNIQUET 18 DISPOSABLE 272 RC outpatient 220.89 176.71 Aetna Commercial PPO 121.49 percent of total billed charges 121.49 187.76 55 of billed Charges STOCKINETTE MILSTEAD 272 RC inpatient 345.49 172.75 BCBS Louisiana PPO 172.75 percent of total billed charges 172.75 293.67 50% of Eligible Charges STOCKINETTE MILSTEAD 272 RC outpatient 345.49 276.39 BCBS Louisiana PPO 276.39 percent of total billed charges 190.02 293.67 80% of billed charge STOCKINETTE MILSTEAD 272 RC outpatient 345.49 276.39 Cigna Commercial PPO 190.02 percent of total billed charges 190.02 293.67 55% of Billed Charges STOCKINETTE MILSTEAD 272 RC inpatient 345.49 172.75 IMA of Louisiana Commercial PPO 293.67 percent of total billed charges 172.75 293.67 Inpatient Reimbursement at 85% of Billed Charges STOCKINETTE MILSTEAD 272 RC outpatient 345.49 276.39 IMA of Louisiana Commercial PPO 293.67 percent of total billed charges 190.02 293.67 Reimbursement at 85% of billed charges STOCKINETTE MILSTEAD 272 RC outpatient 345.49 276.39 Aetna Commercial PPO 190.02 percent of total billed charges 190.02 293.67 55 of billed Charges STATLOCK PICK PLUS W/ PAD 272 RC inpatient 36.08 18.04 BCBS Louisiana PPO 18.04 percent of total billed charges 18.04 30.67 50% of Eligible Charges STATLOCK PICK PLUS W/ PAD 272 RC outpatient 36.08 28.86 BCBS Louisiana PPO 28.86 percent of total billed charges 19.84 30.67 80% of billed charge STATLOCK PICK PLUS W/ PAD 272 RC outpatient 36.08 28.86 Cigna Commercial PPO 19.84 percent of total billed charges 19.84 30.67 55% of Billed Charges STATLOCK PICK PLUS W/ PAD 272 RC inpatient 36.08 18.04 IMA of Louisiana Commercial PPO 30.67 percent of total billed charges 18.04 30.67 Inpatient Reimbursement at 85% of Billed Charges STATLOCK PICK PLUS W/ PAD 272 RC outpatient 36.08 28.86 IMA of Louisiana Commercial PPO 30.67 percent of total billed charges 19.84 30.67 Reimbursement at 85% of billed charges STATLOCK PICK PLUS W/ PAD 272 RC outpatient 36.08 28.86 Aetna Commercial PPO 19.84 percent of total billed charges 19.84 30.67 55 of billed Charges SAW BLADE 2108-309 272 RC inpatient 108.15 54.08 BCBS Louisiana PPO 54.08 percent of total billed charges 54.08 91.93 50% of Eligible Charges SAW BLADE 2108-309 272 RC outpatient 108.15 86.52 BCBS Louisiana PPO 86.52 percent of total billed charges 59.48 91.93 80% of billed charge SAW BLADE 2108-309 272 RC outpatient 108.15 86.52 Cigna Commercial PPO 59.48 percent of total billed charges 59.48 91.93 55% of Billed Charges SAW BLADE 2108-309 272 RC inpatient 108.15 54.08 IMA of Louisiana Commercial PPO 91.93 percent of total billed charges 54.08 91.93 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-309 272 RC outpatient 108.15 86.52 IMA of Louisiana Commercial PPO 91.93 percent of total billed charges 59.48 91.93 Reimbursement at 85% of billed charges SAW BLADE 2108-309 272 RC outpatient 108.15 86.52 Aetna Commercial PPO 59.48 percent of total billed charges 59.48 91.93 55 of billed Charges FOREARM WALKER ATTACHMENT 290 RC inpatient 127.51 63.76 BCBS Louisiana PPO 63.76 percent of total billed charges 63.76 108.38 50% of Eligible Charges FOREARM WALKER ATTACHMENT 290 RC outpatient 127.51 102.01 BCBS Louisiana PPO 102.01 percent of total billed charges 70.13 108.38 80% of billed charge FOREARM WALKER ATTACHMENT 290 RC outpatient 127.51 102.01 Cigna Commercial PPO 70.13 percent of total billed charges 70.13 108.38 55% of Billed Charges FOREARM WALKER ATTACHMENT 290 RC inpatient 127.51 63.76 IMA of Louisiana Commercial PPO 108.38 percent of total billed charges 63.76 108.38 Inpatient Reimbursement at 85% of Billed Charges FOREARM WALKER ATTACHMENT 290 RC outpatient 127.51 102.01 IMA of Louisiana Commercial PPO 108.38 percent of total billed charges 70.13 108.38 Reimbursement at 85% of billed charges FOREARM WALKER ATTACHMENT 290 RC outpatient 127.51 102.01 Aetna Commercial PPO 70.13 percent of total billed charges 70.13 108.38 55 of billed Charges CANE CHROME QUAD 270 RC inpatient 74.2 37.1 BCBS Louisiana PPO 37.1 percent of total billed charges 37.1 63.07 50% of Eligible Charges CANE CHROME QUAD 270 RC outpatient 74.2 59.36 BCBS Louisiana PPO 59.36 percent of total billed charges 40.81 63.07 80% of billed charge CANE CHROME QUAD 270 RC outpatient 74.2 59.36 Cigna Commercial PPO 40.81 percent of total billed charges 40.81 63.07 55% of Billed Charges CANE CHROME QUAD 270 RC inpatient 74.2 37.1 IMA of Louisiana Commercial PPO 63.07 percent of total billed charges 37.1 63.07 Inpatient Reimbursement at 85% of Billed Charges CANE CHROME QUAD 270 RC outpatient 74.2 59.36 IMA of Louisiana Commercial PPO 63.07 percent of total billed charges 40.81 63.07 Reimbursement at 85% of billed charges CANE CHROME QUAD 270 RC outpatient 74.2 59.36 Aetna Commercial PPO 40.81 percent of total billed charges 40.81 63.07 55 of billed Charges SUTURE FIBERWIRE #5 272 RC inpatient 738 369 BCBS Louisiana PPO 369 percent of total billed charges 369 627.3 50% of Eligible Charges SUTURE FIBERWIRE #5 272 RC outpatient 738 590.4 BCBS Louisiana PPO 590.4 percent of total billed charges 405.9 627.3 80% of billed charge SUTURE FIBERWIRE #5 272 RC outpatient 738 590.4 Cigna Commercial PPO 405.9 percent of total billed charges 405.9 627.3 55% of Billed Charges SUTURE FIBERWIRE #5 272 RC inpatient 738 369 IMA of Louisiana Commercial PPO 627.3 percent of total billed charges 369 627.3 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERWIRE #5 272 RC outpatient 738 590.4 IMA of Louisiana Commercial PPO 627.3 percent of total billed charges 405.9 627.3 Reimbursement at 85% of billed charges SUTURE FIBERWIRE #5 272 RC outpatient 738 590.4 Aetna Commercial PPO 405.9 percent of total billed charges 405.9 627.3 55 of billed Charges SUTURE 5-0 PROLENE BV-1 272 RC inpatient 821.31 410.66 BCBS Louisiana PPO 410.66 percent of total billed charges 410.66 698.11 50% of Eligible Charges SUTURE 5-0 PROLENE BV-1 272 RC outpatient 821.31 657.05 BCBS Louisiana PPO 657.05 percent of total billed charges 451.72 698.11 80% of billed charge SUTURE 5-0 PROLENE BV-1 272 RC outpatient 821.31 657.05 Cigna Commercial PPO 451.72 percent of total billed charges 451.72 698.11 55% of Billed Charges SUTURE 5-0 PROLENE BV-1 272 RC inpatient 821.31 410.66 IMA of Louisiana Commercial PPO 698.11 percent of total billed charges 410.66 698.11 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 PROLENE BV-1 272 RC outpatient 821.31 657.05 IMA of Louisiana Commercial PPO 698.11 percent of total billed charges 451.72 698.11 Reimbursement at 85% of billed charges SUTURE 5-0 PROLENE BV-1 272 RC outpatient 821.31 657.05 Aetna Commercial PPO 451.72 percent of total billed charges 451.72 698.11 55 of billed Charges BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 860 430 BCBS Louisiana PPO 430 percent of total billed charges 430 731 50% of Eligible Charges BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 860 688 BCBS Louisiana PPO 688 percent of total billed charges 318.2 731 80% of billed charge BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 860 688 Cigna Commercial PPO 498.8 percent of total billed charges 318.2 731 58% of Billed Charges/$500 Threshold BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC inpatient 860 430 IMA of Louisiana Commercial PPO 731 percent of total billed charges 430 731 Inpatient Reimbursement at 85% of Billed Charges BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 860 688 IMA of Louisiana Commercial PPO 731 percent of total billed charges 318.2 731 Reimbursement at 85% of billed charges BONE 60CC CRUSHED CANCELLOUS C1713 HCPCS 278 RC outpatient 860 688 Aetna Commercial PPO 318.2 percent of total billed charges 318.2 731 37% Of Billed Charges 2000 TEGADERM WITH TELFA 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges TEGADERM WITH TELFA 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge TEGADERM WITH TELFA 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges TEGADERM WITH TELFA 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges TEGADERM WITH TELFA 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges TEGADERM WITH TELFA 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 393.05 196.53 BCBS Louisiana PPO 196.53 percent of total billed charges 196.53 334.09 50% of Eligible Charges SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 BCBS Louisiana PPO 314.44 percent of total billed charges 145.43 334.09 80% of billed charge SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 Cigna Commercial PPO 227.97 percent of total billed charges 145.43 334.09 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 393.05 196.53 IMA of Louisiana Commercial PPO 334.09 percent of total billed charges 196.53 334.09 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 IMA of Louisiana Commercial PPO 334.09 percent of total billed charges 145.43 334.09 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 Aetna Commercial PPO 145.43 percent of total billed charges 145.43 334.09 37% Of Billed Charges 2000 SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SUTURE 3-0 TI-CRON CV-305 272 RC inpatient 431.8 215.9 BCBS Louisiana PPO 215.9 percent of total billed charges 215.9 367.03 50% of Eligible Charges SUTURE 3-0 TI-CRON CV-305 272 RC outpatient 431.8 345.44 BCBS Louisiana PPO 345.44 percent of total billed charges 237.49 367.03 80% of billed charge SUTURE 3-0 TI-CRON CV-305 272 RC outpatient 431.8 345.44 Cigna Commercial PPO 237.49 percent of total billed charges 237.49 367.03 55% of Billed Charges SUTURE 3-0 TI-CRON CV-305 272 RC inpatient 431.8 215.9 IMA of Louisiana Commercial PPO 367.03 percent of total billed charges 215.9 367.03 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 TI-CRON CV-305 272 RC outpatient 431.8 345.44 IMA of Louisiana Commercial PPO 367.03 percent of total billed charges 237.49 367.03 Reimbursement at 85% of billed charges SUTURE 3-0 TI-CRON CV-305 272 RC outpatient 431.8 345.44 Aetna Commercial PPO 237.49 percent of total billed charges 237.49 367.03 55 of billed Charges SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 BCBS Louisiana PPO 235.47 percent of total billed charges 235.47 400.29 50% of Eligible Charges SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 BCBS Louisiana PPO 376.74 percent of total billed charges 174.24 400.29 80% of billed charge SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Cigna Commercial PPO 273.14 percent of total billed charges 174.24 400.29 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 235.47 400.29 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 174.24 400.29 Reimbursement at 85% of billed charges SCREW 4.0MM CANN. 50MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Aetna Commercial PPO 174.24 percent of total billed charges 174.24 400.29 37% Of Billed Charges 2000 SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 SUCTION TUBING 20FT 272 RC inpatient 9.84 4.92 BCBS Louisiana PPO 4.92 percent of total billed charges 4.92 8.36 50% of Eligible Charges SUCTION TUBING 20FT 272 RC outpatient 9.84 7.87 BCBS Louisiana PPO 7.87 percent of total billed charges 5.41 8.36 80% of billed charge SUCTION TUBING 20FT 272 RC outpatient 9.84 7.87 Cigna Commercial PPO 5.41 percent of total billed charges 5.41 8.36 55% of Billed Charges SUCTION TUBING 20FT 272 RC inpatient 9.84 4.92 IMA of Louisiana Commercial PPO 8.36 percent of total billed charges 4.92 8.36 Inpatient Reimbursement at 85% of Billed Charges SUCTION TUBING 20FT 272 RC outpatient 9.84 7.87 IMA of Louisiana Commercial PPO 8.36 percent of total billed charges 5.41 8.36 Reimbursement at 85% of billed charges SUCTION TUBING 20FT 272 RC outpatient 9.84 7.87 Aetna Commercial PPO 5.41 percent of total billed charges 5.41 8.36 55 of billed Charges SUTURE 5 ETHIBOND CCS MB47G 272 RC inpatient 78.84 39.42 BCBS Louisiana PPO 39.42 percent of total billed charges 39.42 67.01 50% of Eligible Charges SUTURE 5 ETHIBOND CCS MB47G 272 RC outpatient 78.84 63.07 BCBS Louisiana PPO 63.07 percent of total billed charges 43.36 67.01 80% of billed charge SUTURE 5 ETHIBOND CCS MB47G 272 RC outpatient 78.84 63.07 Cigna Commercial PPO 43.36 percent of total billed charges 43.36 67.01 55% of Billed Charges SUTURE 5 ETHIBOND CCS MB47G 272 RC inpatient 78.84 39.42 IMA of Louisiana Commercial PPO 67.01 percent of total billed charges 39.42 67.01 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5 ETHIBOND CCS MB47G 272 RC outpatient 78.84 63.07 IMA of Louisiana Commercial PPO 67.01 percent of total billed charges 43.36 67.01 Reimbursement at 85% of billed charges SUTURE 5 ETHIBOND CCS MB47G 272 RC outpatient 78.84 63.07 Aetna Commercial PPO 43.36 percent of total billed charges 43.36 67.01 55 of billed Charges GUIDEWIRE .035 X 150CM - GU DR 272 RC inpatient 781.43 390.72 BCBS Louisiana PPO 390.72 percent of total billed charges 390.72 664.22 50% of Eligible Charges GUIDEWIRE .035 X 150CM - GU DR 272 RC outpatient 781.43 625.14 BCBS Louisiana PPO 625.14 percent of total billed charges 429.79 664.22 80% of billed charge GUIDEWIRE .035 X 150CM - GU DR 272 RC outpatient 781.43 625.14 Cigna Commercial PPO 429.79 percent of total billed charges 429.79 664.22 55% of Billed Charges GUIDEWIRE .035 X 150CM - GU DR 272 RC inpatient 781.43 390.72 IMA of Louisiana Commercial PPO 664.22 percent of total billed charges 390.72 664.22 Inpatient Reimbursement at 85% of Billed Charges GUIDEWIRE .035 X 150CM - GU DR 272 RC outpatient 781.43 625.14 IMA of Louisiana Commercial PPO 664.22 percent of total billed charges 429.79 664.22 Reimbursement at 85% of billed charges GUIDEWIRE .035 X 150CM - GU DR 272 RC outpatient 781.43 625.14 Aetna Commercial PPO 429.79 percent of total billed charges 429.79 664.22 55 of billed Charges TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges TELFA ISLAND DRESSING MINI 2 X 3.75 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges HIPGRIP COVERSETS 270 RC inpatient 495 247.5 BCBS Louisiana PPO 247.5 percent of total billed charges 247.5 420.75 50% of Eligible Charges HIPGRIP COVERSETS 270 RC outpatient 495 396 BCBS Louisiana PPO 396 percent of total billed charges 272.25 420.75 80% of billed charge HIPGRIP COVERSETS 270 RC outpatient 495 396 Cigna Commercial PPO 272.25 percent of total billed charges 272.25 420.75 55% of Billed Charges HIPGRIP COVERSETS 270 RC inpatient 495 247.5 IMA of Louisiana Commercial PPO 420.75 percent of total billed charges 247.5 420.75 Inpatient Reimbursement at 85% of Billed Charges HIPGRIP COVERSETS 270 RC outpatient 495 396 IMA of Louisiana Commercial PPO 420.75 percent of total billed charges 272.25 420.75 Reimbursement at 85% of billed charges HIPGRIP COVERSETS 270 RC outpatient 495 396 Aetna Commercial PPO 272.25 percent of total billed charges 272.25 420.75 55 of billed Charges ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC inpatient 91.04 45.52 BCBS Louisiana PPO 45.52 percent of total billed charges 45.52 77.38 50% of Eligible Charges ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC outpatient 91.04 72.83 BCBS Louisiana PPO 72.83 percent of total billed charges 50.07 77.38 80% of billed charge ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC outpatient 91.04 72.83 Cigna Commercial PPO 50.07 percent of total billed charges 50.07 77.38 55% of Billed Charges ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC inpatient 91.04 45.52 IMA of Louisiana Commercial PPO 77.38 percent of total billed charges 45.52 77.38 Inpatient Reimbursement at 85% of Billed Charges ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC outpatient 91.04 72.83 IMA of Louisiana Commercial PPO 77.38 percent of total billed charges 50.07 77.38 Reimbursement at 85% of billed charges ECHOGENIC NERVE NEEDLE 20GX4 333648 272 RC outpatient 91.04 72.83 Aetna Commercial PPO 50.07 percent of total billed charges 50.07 77.38 55 of billed Charges FIXATION OF SHOULDER 23700 CPT 360 RC inpatient 3285.6 1642.8 BCBS Louisiana PPO 1642.8 percent of total billed charges 1642.8 2792.76 50% of Eligible Charges FIXATION OF SHOULDER 23700 CPT 360 RC outpatient 3285.6 2628.48 BCBS Louisiana PPO 2628.48 percent of total billed charges 1300 2792.76 80% of billed charges FIXATION OF SHOULDER 23700 CPT 360 RC outpatient 3285.6 2628.48 Cigna Commercial PPO 1807.08 percent of total billed charges 1300 2792.76 55% of Billed Charges FIXATION OF SHOULDER 23700 CPT 360 RC inpatient 3285.6 1642.8 IMA of Louisiana Commercial PPO 2792.76 percent of total billed charges 1642.8 2792.76 Inpatient Reimbursement at 85% of Billed Charges FIXATION OF SHOULDER 23700 CPT 360 RC outpatient 3285.6 2628.48 IMA of Louisiana Commercial PPO 2792.76 percent of total billed charges 1300 2792.76 Reimbursement at 85% of billed charges FIXATION OF SHOULDER 23700 CPT 360 RC outpatient 3285.6 2628.48 Aetna Commercial PPO 1300 fee schedule 1300 2792.76 Case Rate NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC inpatient 1596.84 798.42 BCBS Louisiana PPO 798.42 percent of total billed charges 798.42 1357.31 50% of Eligible Charges NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC outpatient 1596.84 1277.47 BCBS Louisiana PPO 1277.47 percent of total billed charges 590.83 1357.31 80% of billed charge NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC outpatient 1596.84 1277.47 Cigna Commercial PPO 926.17 percent of total billed charges 590.83 1357.31 58% of Billed Charges/$500 Threshold NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC inpatient 1596.84 798.42 IMA of Louisiana Commercial PPO 1357.31 percent of total billed charges 798.42 1357.31 Inpatient Reimbursement at 85% of Billed Charges NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC outpatient 1596.84 1277.47 IMA of Louisiana Commercial PPO 1357.31 percent of total billed charges 590.83 1357.31 Reimbursement at 85% of billed charges NEUROSTIMULATOR LEAD TEST KIT C1897 HCPCS 278 RC outpatient 1596.84 1277.47 Aetna Commercial PPO 590.83 percent of total billed charges 590.83 1357.31 37% Of Billed Charges 2000 CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC inpatient 3307.35 1653.68 BCBS Louisiana PPO 1653.68 percent of total billed charges 1653.68 2811.25 50% of Eligible Charges CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC outpatient 3307.35 2645.88 BCBS Louisiana PPO 2645.88 percent of total billed charges 1300 2811.25 80% of billed charges CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC outpatient 3307.35 2645.88 Cigna Commercial PPO 1819.04 percent of total billed charges 1300 2811.25 55% of Billed Charges CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC inpatient 3307.35 1653.68 IMA of Louisiana Commercial PPO 2811.25 percent of total billed charges 1653.68 2811.25 Inpatient Reimbursement at 85% of Billed Charges CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC outpatient 3307.35 2645.88 IMA of Louisiana Commercial PPO 2811.25 percent of total billed charges 1300 2811.25 Reimbursement at 85% of billed charges CLSD TX OF POST HIP ARTHROPLASTY DISLOCA 27266 CPT 360 RC outpatient 3307.35 2645.88 Aetna Commercial PPO 1300 fee schedule 1300 2811.25 Case Rate PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" inpatient 88.15 44.08 BCBS Louisiana PPO 44.08 percent of total billed charges 44.08 74.93 50% of Eligible Charges PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" outpatient 88.15 70.52 BCBS Louisiana PPO 70.52 percent of total billed charges 64.44 85 80% of billed charge PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" outpatient 88.15 70.52 Cigna Commercial PPO 85 other 64.44 85 63% of Billed Charges PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" inpatient 88.15 44.08 IMA of Louisiana Commercial PPO 74.93 percent of total billed charges 44.08 74.93 Inpatient Reimbursement at 85% of Billed Charges PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" outpatient 88.15 70.52 IMA of Louisiana Commercial PPO 74.93 percent of total billed charges 64.44 85 Reimbursement at 85% of billed charges PT NEUROMUSCULAR RE-EDUCATION 97112 CPT 421 RC "GP,59" outpatient 88.15 70.52 Aetna Commercial PPO 64.44 fee schedule 64.44 85 200% Of Aetna Market Fee Schedule PT GAIT TRAINING 97116 CPT 421 RC "GP,59" inpatient 76.7 38.35 BCBS Louisiana PPO 38.35 percent of total billed charges 38.35 65.2 50% of Eligible Charges PT GAIT TRAINING 97116 CPT 421 RC "GP,59" outpatient 76.7 61.36 BCBS Louisiana PPO 61.36 percent of total billed charges 54.28 85 80% of billed charge PT GAIT TRAINING 97116 CPT 421 RC "GP,59" outpatient 76.7 61.36 Cigna Commercial PPO 85 other 54.28 85 63% of Billed Charges PT GAIT TRAINING 97116 CPT 421 RC "GP,59" inpatient 76.7 38.35 IMA of Louisiana Commercial PPO 65.2 percent of total billed charges 38.35 65.2 Inpatient Reimbursement at 85% of Billed Charges PT GAIT TRAINING 97116 CPT 421 RC "GP,59" outpatient 76.7 61.36 IMA of Louisiana Commercial PPO 65.2 percent of total billed charges 54.28 85 Reimbursement at 85% of billed charges PT GAIT TRAINING 97116 CPT 421 RC "GP,59" outpatient 76.7 61.36 Aetna Commercial PPO 54.28 fee schedule 54.28 85 200% Of Aetna Market Fee Schedule PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" inpatient 37.35 18.68 BCBS Louisiana PPO 18.68 percent of total billed charges 18.68 31.75 50% of Eligible Charges PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" outpatient 37.35 29.88 BCBS Louisiana PPO 29.88 percent of total billed charges 29.88 85 80% of billed charge PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" outpatient 37.35 29.88 Cigna Commercial PPO 85 other 29.88 85 63% of Billed Charges PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" inpatient 37.35 18.68 IMA of Louisiana Commercial PPO 31.75 percent of total billed charges 18.68 31.75 Inpatient Reimbursement at 85% of Billed Charges PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" outpatient 37.35 29.88 IMA of Louisiana Commercial PPO 31.75 percent of total billed charges 29.88 85 Reimbursement at 85% of billed charges PT ELECTRICAL STIMULATION UNATTENDED 97014 CPT 421 RC "GP,59" outpatient 37.35 29.88 Aetna Commercial PPO 30.26 fee schedule 29.88 85 200% Of Aetna Market Fee Schedule PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP inpatient 143.1 71.55 BCBS Louisiana PPO 71.55 percent of total billed charges 71.55 121.64 50% of Eligible Charges PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP outpatient 143.1 114.48 BCBS Louisiana PPO 114.48 percent of total billed charges 85 121.64 80% of billed charge PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP outpatient 143.1 114.48 Cigna Commercial PPO 85 other 85 121.64 63% of Billed Charges PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP inpatient 143.1 71.55 IMA of Louisiana Commercial PPO 121.64 percent of total billed charges 71.55 121.64 Inpatient Reimbursement at 85% of Billed Charges PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP outpatient 143.1 114.48 IMA of Louisiana Commercial PPO 121.64 percent of total billed charges 85 121.64 Reimbursement at 85% of billed charges PT RE-EVAL EST PLAN CARE 97164 CPT 424 RC GP outpatient 143.1 114.48 Aetna Commercial PPO 106.34 fee schedule 85 121.64 200% Of Aetna Market Fee Schedule SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 BCBS Louisiana PPO 57.44 percent of total billed charges 57.44 97.64 50% of Eligible Charges SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 BCBS Louisiana PPO 91.9 percent of total billed charges 42.5 97.64 80% of billed charge SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Cigna Commercial PPO 66.62 percent of total billed charges 42.5 97.64 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 57.44 97.64 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 42.5 97.64 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 9MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Aetna Commercial PPO 42.5 percent of total billed charges 42.5 97.64 37% Of Billed Charges 2000 SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 265.93 132.97 BCBS Louisiana PPO 132.97 percent of total billed charges 132.97 226.04 50% of Eligible Charges SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 BCBS Louisiana PPO 212.74 percent of total billed charges 98.39 226.04 80% of billed charge SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 Cigna Commercial PPO 154.24 percent of total billed charges 98.39 226.04 58% of Billed Charges/$500 Threshold SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 265.93 132.97 IMA of Louisiana Commercial PPO 226.04 percent of total billed charges 132.97 226.04 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 IMA of Louisiana Commercial PPO 226.04 percent of total billed charges 98.39 226.04 Reimbursement at 85% of billed charges SCREW 2.4MM CORTEX 13MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 Aetna Commercial PPO 98.39 percent of total billed charges 98.39 226.04 37% Of Billed Charges 2000 PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 508.73 254.37 BCBS Louisiana PPO 254.37 percent of total billed charges 254.37 432.42 50% of Eligible Charges PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 508.73 406.98 BCBS Louisiana PPO 406.98 percent of total billed charges 188.23 432.42 80% of billed charge PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 508.73 406.98 Cigna Commercial PPO 295.06 percent of total billed charges 188.23 432.42 58% of Billed Charges/$500 Threshold PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 508.73 254.37 IMA of Louisiana Commercial PPO 432.42 percent of total billed charges 254.37 432.42 Inpatient Reimbursement at 85% of Billed Charges PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 508.73 406.98 IMA of Louisiana Commercial PPO 432.42 percent of total billed charges 188.23 432.42 Reimbursement at 85% of billed charges PLATE 2.0MM T 2 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 508.73 406.98 Aetna Commercial PPO 188.23 percent of total billed charges 188.23 432.42 37% Of Billed Charges 2000 GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC inpatient 293.3 146.65 BCBS Louisiana PPO 146.65 percent of total billed charges 146.65 249.31 50% of Eligible Charges GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC outpatient 293.3 234.64 BCBS Louisiana PPO 234.64 percent of total billed charges 161.32 249.31 80% of billed charge GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC outpatient 293.3 234.64 Cigna Commercial PPO 161.32 percent of total billed charges 161.32 249.31 55% of Billed Charges GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC inpatient 293.3 146.65 IMA of Louisiana Commercial PPO 249.31 percent of total billed charges 146.65 249.31 Inpatient Reimbursement at 85% of Billed Charges GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC outpatient 293.3 234.64 IMA of Louisiana Commercial PPO 249.31 percent of total billed charges 161.32 249.31 Reimbursement at 85% of billed charges GUIDEWIRE 2.8MM W/FLUTE 292.81 272 RC outpatient 293.3 234.64 Aetna Commercial PPO 161.32 percent of total billed charges 161.32 249.31 55 of billed Charges GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC inpatient 288.55 144.28 BCBS Louisiana PPO 144.28 percent of total billed charges 144.28 245.27 50% of Eligible Charges GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC outpatient 288.55 230.84 BCBS Louisiana PPO 230.84 percent of total billed charges 158.7 245.27 80% of billed charge GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC outpatient 288.55 230.84 Cigna Commercial PPO 158.7 percent of total billed charges 158.7 245.27 55% of Billed Charges GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC inpatient 288.55 144.28 IMA of Louisiana Commercial PPO 245.27 percent of total billed charges 144.28 245.27 Inpatient Reimbursement at 85% of Billed Charges GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC outpatient 288.55 230.84 IMA of Louisiana Commercial PPO 245.27 percent of total billed charges 158.7 245.27 Reimbursement at 85% of billed charges GUIDEWIRE 2.8MM 450MM/300MM 900.726 272 RC outpatient 288.55 230.84 Aetna Commercial PPO 158.7 percent of total billed charges 158.7 245.27 55 of billed Charges CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC inpatient 78.71 39.36 BCBS Louisiana PPO 39.36 percent of total billed charges 39.36 66.9 50% of Eligible Charges CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC outpatient 78.71 62.97 BCBS Louisiana PPO 62.97 percent of total billed charges 43.29 66.9 80% of billed charge CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC outpatient 78.71 62.97 Cigna Commercial PPO 43.29 percent of total billed charges 43.29 66.9 55% of Billed Charges CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC inpatient 78.71 39.36 IMA of Louisiana Commercial PPO 66.9 percent of total billed charges 39.36 66.9 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC outpatient 78.71 62.97 IMA of Louisiana Commercial PPO 66.9 percent of total billed charges 43.29 66.9 Reimbursement at 85% of billed charges CATHETER FOLEY COUNCIL TIP 2WAY 18FR 272 RC outpatient 78.71 62.97 Aetna Commercial PPO 43.29 percent of total billed charges 43.29 66.9 55 of billed Charges SUTURE 5 ETHIBOND V-40 MB46G 272 RC inpatient 71.32 35.66 BCBS Louisiana PPO 35.66 percent of total billed charges 35.66 60.62 50% of Eligible Charges SUTURE 5 ETHIBOND V-40 MB46G 272 RC outpatient 71.32 57.06 BCBS Louisiana PPO 57.06 percent of total billed charges 39.23 60.62 80% of billed charge SUTURE 5 ETHIBOND V-40 MB46G 272 RC outpatient 71.32 57.06 Cigna Commercial PPO 39.23 percent of total billed charges 39.23 60.62 55% of Billed Charges SUTURE 5 ETHIBOND V-40 MB46G 272 RC inpatient 71.32 35.66 IMA of Louisiana Commercial PPO 60.62 percent of total billed charges 35.66 60.62 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5 ETHIBOND V-40 MB46G 272 RC outpatient 71.32 57.06 IMA of Louisiana Commercial PPO 60.62 percent of total billed charges 39.23 60.62 Reimbursement at 85% of billed charges SUTURE 5 ETHIBOND V-40 MB46G 272 RC outpatient 71.32 57.06 Aetna Commercial PPO 39.23 percent of total billed charges 39.23 60.62 55 of billed Charges DRAPE LAP/PELVIS #89219 272 RC inpatient 117.67 58.84 BCBS Louisiana PPO 58.84 percent of total billed charges 58.84 100.02 50% of Eligible Charges DRAPE LAP/PELVIS #89219 272 RC outpatient 117.67 94.14 BCBS Louisiana PPO 94.14 percent of total billed charges 64.72 100.02 80% of billed charge DRAPE LAP/PELVIS #89219 272 RC outpatient 117.67 94.14 Cigna Commercial PPO 64.72 percent of total billed charges 64.72 100.02 55% of Billed Charges DRAPE LAP/PELVIS #89219 272 RC inpatient 117.67 58.84 IMA of Louisiana Commercial PPO 100.02 percent of total billed charges 58.84 100.02 Inpatient Reimbursement at 85% of Billed Charges DRAPE LAP/PELVIS #89219 272 RC outpatient 117.67 94.14 IMA of Louisiana Commercial PPO 100.02 percent of total billed charges 64.72 100.02 Reimbursement at 85% of billed charges DRAPE LAP/PELVIS #89219 272 RC outpatient 117.67 94.14 Aetna Commercial PPO 64.72 percent of total billed charges 64.72 100.02 55 of billed Charges SUTURE 6-0 ETHILON P-3 1698G 272 RC inpatient 15.84 7.92 BCBS Louisiana PPO 7.92 percent of total billed charges 7.92 13.46 50% of Eligible Charges SUTURE 6-0 ETHILON P-3 1698G 272 RC outpatient 15.84 12.67 BCBS Louisiana PPO 12.67 percent of total billed charges 8.71 13.46 80% of billed charge SUTURE 6-0 ETHILON P-3 1698G 272 RC outpatient 15.84 12.67 Cigna Commercial PPO 8.71 percent of total billed charges 8.71 13.46 55% of Billed Charges SUTURE 6-0 ETHILON P-3 1698G 272 RC inpatient 15.84 7.92 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 7.92 13.46 Inpatient Reimbursement at 85% of Billed Charges SUTURE 6-0 ETHILON P-3 1698G 272 RC outpatient 15.84 12.67 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 8.71 13.46 Reimbursement at 85% of billed charges SUTURE 6-0 ETHILON P-3 1698G 272 RC outpatient 15.84 12.67 Aetna Commercial PPO 8.71 percent of total billed charges 8.71 13.46 55 of billed Charges DRAPE PEDI LAP--NUNLEY 272 RC inpatient 47.64 23.82 BCBS Louisiana PPO 23.82 percent of total billed charges 23.82 40.49 50% of Eligible Charges DRAPE PEDI LAP--NUNLEY 272 RC outpatient 47.64 38.11 BCBS Louisiana PPO 38.11 percent of total billed charges 26.2 40.49 80% of billed charge DRAPE PEDI LAP--NUNLEY 272 RC outpatient 47.64 38.11 Cigna Commercial PPO 26.2 percent of total billed charges 26.2 40.49 55% of Billed Charges DRAPE PEDI LAP--NUNLEY 272 RC inpatient 47.64 23.82 IMA of Louisiana Commercial PPO 40.49 percent of total billed charges 23.82 40.49 Inpatient Reimbursement at 85% of Billed Charges DRAPE PEDI LAP--NUNLEY 272 RC outpatient 47.64 38.11 IMA of Louisiana Commercial PPO 40.49 percent of total billed charges 26.2 40.49 Reimbursement at 85% of billed charges DRAPE PEDI LAP--NUNLEY 272 RC outpatient 47.64 38.11 Aetna Commercial PPO 26.2 percent of total billed charges 26.2 40.49 55 of billed Charges SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC inpatient 750 375 BCBS Louisiana PPO 375 percent of total billed charges 375 637.5 50% of Eligible Charges SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC outpatient 750 600 BCBS Louisiana PPO 600 percent of total billed charges 277.5 637.5 80% of billed charge SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC outpatient 750 600 Cigna Commercial PPO 435 percent of total billed charges 277.5 637.5 58% of Billed Charges/$500 Threshold SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC inpatient 750 375 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 375 637.5 Inpatient Reimbursement at 85% of Billed Charges SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC outpatient 750 600 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 277.5 637.5 Reimbursement at 85% of billed charges SCREW 1.2MM TI EMERGENCY 400.610 C1713 HCPCS 278 RC outpatient 750 600 Aetna Commercial PPO 277.5 percent of total billed charges 277.5 637.5 37% Of Billed Charges 2000 GLIDESCOPE GVL #3 STAT 272 RC inpatient 604.8 302.4 BCBS Louisiana PPO 302.4 percent of total billed charges 302.4 514.08 50% of Eligible Charges GLIDESCOPE GVL #3 STAT 272 RC outpatient 604.8 483.84 BCBS Louisiana PPO 483.84 percent of total billed charges 332.64 514.08 80% of billed charge GLIDESCOPE GVL #3 STAT 272 RC outpatient 604.8 483.84 Cigna Commercial PPO 332.64 percent of total billed charges 332.64 514.08 55% of Billed Charges GLIDESCOPE GVL #3 STAT 272 RC inpatient 604.8 302.4 IMA of Louisiana Commercial PPO 514.08 percent of total billed charges 302.4 514.08 Inpatient Reimbursement at 85% of Billed Charges GLIDESCOPE GVL #3 STAT 272 RC outpatient 604.8 483.84 IMA of Louisiana Commercial PPO 514.08 percent of total billed charges 332.64 514.08 Reimbursement at 85% of billed charges GLIDESCOPE GVL #3 STAT 272 RC outpatient 604.8 483.84 Aetna Commercial PPO 332.64 percent of total billed charges 332.64 514.08 55 of billed Charges NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC inpatient 20.6 10.3 BCBS Louisiana PPO 10.3 percent of total billed charges 10.3 17.51 50% of Eligible Charges NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC outpatient 20.6 16.48 BCBS Louisiana PPO 16.48 percent of total billed charges 11.33 17.51 80% of billed charge NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC outpatient 20.6 16.48 Cigna Commercial PPO 11.33 percent of total billed charges 11.33 17.51 55% of Billed Charges NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC inpatient 20.6 10.3 IMA of Louisiana Commercial PPO 17.51 percent of total billed charges 10.3 17.51 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC outpatient 20.6 16.48 IMA of Louisiana Commercial PPO 17.51 percent of total billed charges 11.33 17.51 Reimbursement at 85% of billed charges NEEDLE SPINAL 25G X 4 3/4 PENCAN - ANEST 272 RC outpatient 20.6 16.48 Aetna Commercial PPO 11.33 percent of total billed charges 11.33 17.51 55 of billed Charges BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC inpatient 347.13 173.57 BCBS Louisiana PPO 173.57 percent of total billed charges 173.57 295.06 50% of Eligible Charges BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC outpatient 347.13 277.7 BCBS Louisiana PPO 277.7 percent of total billed charges 190.92 295.06 80% of billed charge BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC outpatient 347.13 277.7 Cigna Commercial PPO 190.92 percent of total billed charges 190.92 295.06 55% of Billed Charges BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC inpatient 347.13 173.57 IMA of Louisiana Commercial PPO 295.06 percent of total billed charges 173.57 295.06 Inpatient Reimbursement at 85% of Billed Charges BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC outpatient 347.13 277.7 IMA of Louisiana Commercial PPO 295.06 percent of total billed charges 190.92 295.06 Reimbursement at 85% of billed charges BALLTIP GUIDEWIRE REAMING PROBE 2.5MM 272 RC outpatient 347.13 277.7 Aetna Commercial PPO 190.92 percent of total billed charges 190.92 295.06 55 of billed Charges BUR MIDAS #8MH17 - CAMPBELL 272 RC inpatient 311.68 155.84 BCBS Louisiana PPO 155.84 percent of total billed charges 155.84 264.93 50% of Eligible Charges BUR MIDAS #8MH17 - CAMPBELL 272 RC outpatient 311.68 249.34 BCBS Louisiana PPO 249.34 percent of total billed charges 171.42 264.93 80% of billed charge BUR MIDAS #8MH17 - CAMPBELL 272 RC outpatient 311.68 249.34 Cigna Commercial PPO 171.42 percent of total billed charges 171.42 264.93 55% of Billed Charges BUR MIDAS #8MH17 - CAMPBELL 272 RC inpatient 311.68 155.84 IMA of Louisiana Commercial PPO 264.93 percent of total billed charges 155.84 264.93 Inpatient Reimbursement at 85% of Billed Charges BUR MIDAS #8MH17 - CAMPBELL 272 RC outpatient 311.68 249.34 IMA of Louisiana Commercial PPO 264.93 percent of total billed charges 171.42 264.93 Reimbursement at 85% of billed charges BUR MIDAS #8MH17 - CAMPBELL 272 RC outpatient 311.68 249.34 Aetna Commercial PPO 171.42 percent of total billed charges 171.42 264.93 55 of billed Charges TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC inpatient 10.88 5.44 BCBS Louisiana PPO 5.44 percent of total billed charges 5.44 9.25 50% of Eligible Charges TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC outpatient 10.88 8.7 BCBS Louisiana PPO 8.7 percent of total billed charges 5.98 9.25 80% of billed charge TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC outpatient 10.88 8.7 Cigna Commercial PPO 5.98 percent of total billed charges 5.98 9.25 55% of Billed Charges TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC inpatient 10.88 5.44 IMA of Louisiana Commercial PPO 9.25 percent of total billed charges 5.44 9.25 Inpatient Reimbursement at 85% of Billed Charges TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC outpatient 10.88 8.7 IMA of Louisiana Commercial PPO 9.25 percent of total billed charges 5.98 9.25 Reimbursement at 85% of billed charges TOWEL BLUE STERILE - HAYNIE/PAIN 272 RC outpatient 10.88 8.7 Aetna Commercial PPO 5.98 percent of total billed charges 5.98 9.25 55 of billed Charges SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC inpatient 297.5 148.75 BCBS Louisiana PPO 148.75 percent of total billed charges 148.75 252.88 50% of Eligible Charges SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 297.5 238 BCBS Louisiana PPO 238 percent of total billed charges 110.08 252.88 80% of billed charge SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 297.5 238 Cigna Commercial PPO 172.55 percent of total billed charges 110.08 252.88 58% of Billed Charges/$500 Threshold SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC inpatient 297.5 148.75 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 148.75 252.88 Inpatient Reimbursement at 85% of Billed Charges SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 297.5 238 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 110.08 252.88 Reimbursement at 85% of billed charges SCREW 1.2MMX8MM TI EMERGENCY 400.612 C1713 HCPCS 278 RC outpatient 297.5 238 Aetna Commercial PPO 110.08 percent of total billed charges 110.08 252.88 37% Of Billed Charges 2000 RIO DRAPE KIT - MAKO 272 RC inpatient 150.96 75.48 BCBS Louisiana PPO 75.48 percent of total billed charges 75.48 128.32 50% of Eligible Charges RIO DRAPE KIT - MAKO 272 RC outpatient 150.96 120.77 BCBS Louisiana PPO 120.77 percent of total billed charges 83.03 128.32 80% of billed charge RIO DRAPE KIT - MAKO 272 RC outpatient 150.96 120.77 Cigna Commercial PPO 83.03 percent of total billed charges 83.03 128.32 55% of Billed Charges RIO DRAPE KIT - MAKO 272 RC inpatient 150.96 75.48 IMA of Louisiana Commercial PPO 128.32 percent of total billed charges 75.48 128.32 Inpatient Reimbursement at 85% of Billed Charges RIO DRAPE KIT - MAKO 272 RC outpatient 150.96 120.77 IMA of Louisiana Commercial PPO 128.32 percent of total billed charges 83.03 128.32 Reimbursement at 85% of billed charges RIO DRAPE KIT - MAKO 272 RC outpatient 150.96 120.77 Aetna Commercial PPO 83.03 percent of total billed charges 83.03 128.32 55 of billed Charges BONE PIN 4 X 80MM - MAKO 272 RC inpatient 403.2 201.6 BCBS Louisiana PPO 201.6 percent of total billed charges 201.6 342.72 50% of Eligible Charges BONE PIN 4 X 80MM - MAKO 272 RC outpatient 403.2 322.56 BCBS Louisiana PPO 322.56 percent of total billed charges 221.76 342.72 80% of billed charge BONE PIN 4 X 80MM - MAKO 272 RC outpatient 403.2 322.56 Cigna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55% of Billed Charges BONE PIN 4 X 80MM - MAKO 272 RC inpatient 403.2 201.6 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 201.6 342.72 Inpatient Reimbursement at 85% of Billed Charges BONE PIN 4 X 80MM - MAKO 272 RC outpatient 403.2 322.56 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 221.76 342.72 Reimbursement at 85% of billed charges BONE PIN 4 X 80MM - MAKO 272 RC outpatient 403.2 322.56 Aetna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55 of billed Charges "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC inpatient 55.2 27.6 BCBS Louisiana PPO 27.6 percent of total billed charges 27.6 46.92 50% of Eligible Charges "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC outpatient 55.2 44.16 BCBS Louisiana PPO 44.16 percent of total billed charges 30.36 46.92 80% of billed charge "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC outpatient 55.2 44.16 Cigna Commercial PPO 30.36 percent of total billed charges 30.36 46.92 55% of Billed Charges "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC inpatient 55.2 27.6 IMA of Louisiana Commercial PPO 46.92 percent of total billed charges 27.6 46.92 Inpatient Reimbursement at 85% of Billed Charges "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC outpatient 55.2 44.16 IMA of Louisiana Commercial PPO 46.92 percent of total billed charges 30.36 46.92 Reimbursement at 85% of billed charges "CATHETER, ANGIO 12G X 3 --UTTER" 272 RC outpatient 55.2 44.16 Aetna Commercial PPO 30.36 percent of total billed charges 30.36 46.92 55 of billed Charges POUCH IRR HIP- ACURIO 272 RC inpatient 17.12 8.56 BCBS Louisiana PPO 8.56 percent of total billed charges 8.56 14.55 50% of Eligible Charges POUCH IRR HIP- ACURIO 272 RC outpatient 17.12 13.7 BCBS Louisiana PPO 13.7 percent of total billed charges 9.42 14.55 80% of billed charge POUCH IRR HIP- ACURIO 272 RC outpatient 17.12 13.7 Cigna Commercial PPO 9.42 percent of total billed charges 9.42 14.55 55% of Billed Charges POUCH IRR HIP- ACURIO 272 RC inpatient 17.12 8.56 IMA of Louisiana Commercial PPO 14.55 percent of total billed charges 8.56 14.55 Inpatient Reimbursement at 85% of Billed Charges POUCH IRR HIP- ACURIO 272 RC outpatient 17.12 13.7 IMA of Louisiana Commercial PPO 14.55 percent of total billed charges 9.42 14.55 Reimbursement at 85% of billed charges POUCH IRR HIP- ACURIO 272 RC outpatient 17.12 13.7 Aetna Commercial PPO 9.42 percent of total billed charges 9.42 14.55 55 of billed Charges SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 212.134 C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SUTURE 7-0 ETHILON P-1 1696G 272 RC inpatient 159.39 79.7 BCBS Louisiana PPO 79.7 percent of total billed charges 79.7 135.48 50% of Eligible Charges SUTURE 7-0 ETHILON P-1 1696G 272 RC outpatient 159.39 127.51 BCBS Louisiana PPO 127.51 percent of total billed charges 87.66 135.48 80% of billed charge SUTURE 7-0 ETHILON P-1 1696G 272 RC outpatient 159.39 127.51 Cigna Commercial PPO 87.66 percent of total billed charges 87.66 135.48 55% of Billed Charges SUTURE 7-0 ETHILON P-1 1696G 272 RC inpatient 159.39 79.7 IMA of Louisiana Commercial PPO 135.48 percent of total billed charges 79.7 135.48 Inpatient Reimbursement at 85% of Billed Charges SUTURE 7-0 ETHILON P-1 1696G 272 RC outpatient 159.39 127.51 IMA of Louisiana Commercial PPO 135.48 percent of total billed charges 87.66 135.48 Reimbursement at 85% of billed charges SUTURE 7-0 ETHILON P-1 1696G 272 RC outpatient 159.39 127.51 Aetna Commercial PPO 87.66 percent of total billed charges 87.66 135.48 55 of billed Charges GENERAL ANES. TIVA - SUPPLIES 270 RC inpatient 114.95 57.48 BCBS Louisiana PPO 57.48 percent of total billed charges 57.48 97.71 50% of Eligible Charges GENERAL ANES. TIVA - SUPPLIES 270 RC outpatient 114.95 91.96 BCBS Louisiana PPO 91.96 percent of total billed charges 63.22 97.71 80% of billed charge GENERAL ANES. TIVA - SUPPLIES 270 RC outpatient 114.95 91.96 Cigna Commercial PPO 63.22 percent of total billed charges 63.22 97.71 55% of Billed Charges GENERAL ANES. TIVA - SUPPLIES 270 RC inpatient 114.95 57.48 IMA of Louisiana Commercial PPO 97.71 percent of total billed charges 57.48 97.71 Inpatient Reimbursement at 85% of Billed Charges GENERAL ANES. TIVA - SUPPLIES 270 RC outpatient 114.95 91.96 IMA of Louisiana Commercial PPO 97.71 percent of total billed charges 63.22 97.71 Reimbursement at 85% of billed charges GENERAL ANES. TIVA - SUPPLIES 270 RC outpatient 114.95 91.96 Aetna Commercial PPO 63.22 percent of total billed charges 63.22 97.71 55 of billed Charges DRAPE CAMERA 272 RC inpatient 179.83 89.92 BCBS Louisiana PPO 89.92 percent of total billed charges 89.92 152.86 50% of Eligible Charges DRAPE CAMERA 272 RC outpatient 179.83 143.86 BCBS Louisiana PPO 143.86 percent of total billed charges 98.91 152.86 80% of billed charge DRAPE CAMERA 272 RC outpatient 179.83 143.86 Cigna Commercial PPO 98.91 percent of total billed charges 98.91 152.86 55% of Billed Charges DRAPE CAMERA 272 RC inpatient 179.83 89.92 IMA of Louisiana Commercial PPO 152.86 percent of total billed charges 89.92 152.86 Inpatient Reimbursement at 85% of Billed Charges DRAPE CAMERA 272 RC outpatient 179.83 143.86 IMA of Louisiana Commercial PPO 152.86 percent of total billed charges 98.91 152.86 Reimbursement at 85% of billed charges DRAPE CAMERA 272 RC outpatient 179.83 143.86 Aetna Commercial PPO 98.91 percent of total billed charges 98.91 152.86 55 of billed Charges PRIMARY IV TUBING FOR OUT PTS 272 RC inpatient 10.61 5.31 BCBS Louisiana PPO 5.31 percent of total billed charges 5.31 9.02 50% of Eligible Charges PRIMARY IV TUBING FOR OUT PTS 272 RC outpatient 10.61 8.49 BCBS Louisiana PPO 8.49 percent of total billed charges 5.84 9.02 80% of billed charge PRIMARY IV TUBING FOR OUT PTS 272 RC outpatient 10.61 8.49 Cigna Commercial PPO 5.84 percent of total billed charges 5.84 9.02 55% of Billed Charges PRIMARY IV TUBING FOR OUT PTS 272 RC inpatient 10.61 5.31 IMA of Louisiana Commercial PPO 9.02 percent of total billed charges 5.31 9.02 Inpatient Reimbursement at 85% of Billed Charges PRIMARY IV TUBING FOR OUT PTS 272 RC outpatient 10.61 8.49 IMA of Louisiana Commercial PPO 9.02 percent of total billed charges 5.84 9.02 Reimbursement at 85% of billed charges PRIMARY IV TUBING FOR OUT PTS 272 RC outpatient 10.61 8.49 Aetna Commercial PPO 5.84 percent of total billed charges 5.84 9.02 55 of billed Charges INCISION OF FOOT FASCIA 28008 CPT 360 RC inpatient 5621.13 2810.57 BCBS Louisiana PPO 2810.57 percent of total billed charges 2810.57 4777.96 50% of Eligible Charges INCISION OF FOOT FASCIA 28008 CPT 360 RC outpatient 5621.13 4496.9 BCBS Louisiana PPO 4496.9 percent of total billed charges 1300 4777.96 80% of billed charges INCISION OF FOOT FASCIA 28008 CPT 360 RC outpatient 5621.13 4496.9 Cigna Commercial PPO 3091.62 percent of total billed charges 1300 4777.96 55% of Billed Charges INCISION OF FOOT FASCIA 28008 CPT 360 RC inpatient 5621.13 2810.57 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 2810.57 4777.96 Inpatient Reimbursement at 85% of Billed Charges INCISION OF FOOT FASCIA 28008 CPT 360 RC outpatient 5621.13 4496.9 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 1300 4777.96 Reimbursement at 85% of billed charges INCISION OF FOOT FASCIA 28008 CPT 360 RC outpatient 5621.13 4496.9 Aetna Commercial PPO 1300 fee schedule 1300 4777.96 Case Rate "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges "NBLOCK, OTHER PERIPHERAL" 64450 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" inpatient 101.88 50.94 BCBS Louisiana PPO 50.94 percent of total billed charges 50.94 86.6 50% of Eligible Charges PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" outpatient 101.88 81.5 BCBS Louisiana PPO 81.5 percent of total billed charges 66.04 86.6 80% of billed charge PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" outpatient 101.88 81.5 Cigna Commercial PPO 85 other 66.04 86.6 63% of Billed Charges PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" inpatient 101.88 50.94 IMA of Louisiana Commercial PPO 86.6 percent of total billed charges 50.94 86.6 Inpatient Reimbursement at 85% of Billed Charges PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" outpatient 101.88 81.5 IMA of Louisiana Commercial PPO 86.6 percent of total billed charges 66.04 86.6 Reimbursement at 85% of billed charges PT THERAPEUTIC ACTIVITIES 97530 CPT 421 RC "GP,59" outpatient 101.88 81.5 Aetna Commercial PPO 66.04 fee schedule 66.04 86.6 200% Of Aetna Market Fee Schedule PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" inpatient 117.7 58.85 BCBS Louisiana PPO 58.85 percent of total billed charges 58.85 100.05 50% of Eligible Charges PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" outpatient 117.7 94.16 BCBS Louisiana PPO 94.16 percent of total billed charges 64.74 100.05 80% of billed charge PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" outpatient 117.7 94.16 Cigna Commercial PPO 85 other 64.74 100.05 63% of Billed Charges PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" inpatient 117.7 58.85 IMA of Louisiana Commercial PPO 100.05 percent of total billed charges 58.85 100.05 Inpatient Reimbursement at 85% of Billed Charges PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" outpatient 117.7 94.16 IMA of Louisiana Commercial PPO 100.05 percent of total billed charges 64.74 100.05 Reimbursement at 85% of billed charges PT ORTHOTIC TRAINING 97760 CPT 421 RC "GP,59" outpatient 117.7 94.16 Aetna Commercial PPO 64.74 percent of total billed charges 64.74 100.05 55 of billed Charges PT HOT/COLD PACKS 97010 CPT 421 RC GP inpatient 4.09 2.05 BCBS Louisiana PPO 2.05 percent of total billed charges 2.05 3.48 50% of Eligible Charges PT HOT/COLD PACKS 97010 CPT 421 RC GP outpatient 4.09 3.27 BCBS Louisiana PPO 3.27 percent of total billed charges 3.27 85 80% of billed charge PT HOT/COLD PACKS 97010 CPT 421 RC GP outpatient 4.09 3.27 Cigna Commercial PPO 85 other 3.27 85 63% of Billed Charges PT HOT/COLD PACKS 97010 CPT 421 RC GP inpatient 4.09 2.05 IMA of Louisiana Commercial PPO 3.48 percent of total billed charges 2.05 3.48 Inpatient Reimbursement at 85% of Billed Charges PT HOT/COLD PACKS 97010 CPT 421 RC GP outpatient 4.09 3.27 IMA of Louisiana Commercial PPO 3.48 percent of total billed charges 3.27 85 Reimbursement at 85% of billed charges PT HOT/COLD PACKS 97010 CPT 421 RC GP outpatient 4.09 3.27 Aetna Commercial PPO 11.52 fee schedule 3.27 85 200% Of Aetna Market Fee Schedule PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" inpatient 87.13 43.57 BCBS Louisiana PPO 43.57 percent of total billed charges 43.57 74.06 50% of Eligible Charges PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" outpatient 87.13 69.7 BCBS Louisiana PPO 69.7 percent of total billed charges 66.98 85 80% of billed charge PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" outpatient 87.13 69.7 Cigna Commercial PPO 85 other 66.98 85 63% of Billed Charges PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" inpatient 87.13 43.57 IMA of Louisiana Commercial PPO 74.06 percent of total billed charges 43.57 74.06 Inpatient Reimbursement at 85% of Billed Charges PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" outpatient 87.13 69.7 IMA of Louisiana Commercial PPO 74.06 percent of total billed charges 66.98 85 Reimbursement at 85% of billed charges PT SELF CARE HOME MANAGEMENT 97535 CPT 421 RC "GP,59" outpatient 87.13 69.7 Aetna Commercial PPO 66.98 fee schedule 66.98 85 200% Of Aetna Market Fee Schedule SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 265.93 132.97 BCBS Louisiana PPO 132.97 percent of total billed charges 132.97 226.04 50% of Eligible Charges SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 BCBS Louisiana PPO 212.74 percent of total billed charges 98.39 226.04 80% of billed charge SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 Cigna Commercial PPO 154.24 percent of total billed charges 98.39 226.04 58% of Billed Charges/$500 Threshold SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 265.93 132.97 IMA of Louisiana Commercial PPO 226.04 percent of total billed charges 132.97 226.04 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 IMA of Louisiana Commercial PPO 226.04 percent of total billed charges 98.39 226.04 Reimbursement at 85% of billed charges SCREW 2.4MM CORTEX 14MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 265.93 212.74 Aetna Commercial PPO 98.39 percent of total billed charges 98.39 226.04 37% Of Billed Charges 2000 KNEE BRACE BLEDSO 22 270 RC inpatient 433.13 216.57 BCBS Louisiana PPO 216.57 percent of total billed charges 216.57 368.16 50% of Eligible Charges KNEE BRACE BLEDSO 22 270 RC outpatient 433.13 346.5 BCBS Louisiana PPO 346.5 percent of total billed charges 238.22 368.16 80% of billed charge KNEE BRACE BLEDSO 22 270 RC outpatient 433.13 346.5 Cigna Commercial PPO 238.22 percent of total billed charges 238.22 368.16 55% of Billed Charges KNEE BRACE BLEDSO 22 270 RC inpatient 433.13 216.57 IMA of Louisiana Commercial PPO 368.16 percent of total billed charges 216.57 368.16 Inpatient Reimbursement at 85% of Billed Charges KNEE BRACE BLEDSO 22 270 RC outpatient 433.13 346.5 IMA of Louisiana Commercial PPO 368.16 percent of total billed charges 238.22 368.16 Reimbursement at 85% of billed charges KNEE BRACE BLEDSO 22 270 RC outpatient 433.13 346.5 Aetna Commercial PPO 238.22 percent of total billed charges 238.22 368.16 55 of billed Charges HIBICLENS SCRUB TRAY 272 RC inpatient 68.56 34.28 BCBS Louisiana PPO 34.28 percent of total billed charges 34.28 58.28 50% of Eligible Charges HIBICLENS SCRUB TRAY 272 RC outpatient 68.56 54.85 BCBS Louisiana PPO 54.85 percent of total billed charges 37.71 58.28 80% of billed charge HIBICLENS SCRUB TRAY 272 RC outpatient 68.56 54.85 Cigna Commercial PPO 37.71 percent of total billed charges 37.71 58.28 55% of Billed Charges HIBICLENS SCRUB TRAY 272 RC inpatient 68.56 34.28 IMA of Louisiana Commercial PPO 58.28 percent of total billed charges 34.28 58.28 Inpatient Reimbursement at 85% of Billed Charges HIBICLENS SCRUB TRAY 272 RC outpatient 68.56 54.85 IMA of Louisiana Commercial PPO 58.28 percent of total billed charges 37.71 58.28 Reimbursement at 85% of billed charges HIBICLENS SCRUB TRAY 272 RC outpatient 68.56 54.85 Aetna Commercial PPO 37.71 percent of total billed charges 37.71 58.28 55 of billed Charges WRIST STRAP FOR TOWER REF 10170060 270 RC inpatient 192.5 96.25 BCBS Louisiana PPO 96.25 percent of total billed charges 96.25 163.63 50% of Eligible Charges WRIST STRAP FOR TOWER REF 10170060 270 RC outpatient 192.5 154 BCBS Louisiana PPO 154 percent of total billed charges 105.88 163.63 80% of billed charge WRIST STRAP FOR TOWER REF 10170060 270 RC outpatient 192.5 154 Cigna Commercial PPO 105.88 percent of total billed charges 105.88 163.63 55% of Billed Charges WRIST STRAP FOR TOWER REF 10170060 270 RC inpatient 192.5 96.25 IMA of Louisiana Commercial PPO 163.63 percent of total billed charges 96.25 163.63 Inpatient Reimbursement at 85% of Billed Charges WRIST STRAP FOR TOWER REF 10170060 270 RC outpatient 192.5 154 IMA of Louisiana Commercial PPO 163.63 percent of total billed charges 105.88 163.63 Reimbursement at 85% of billed charges WRIST STRAP FOR TOWER REF 10170060 270 RC outpatient 192.5 154 Aetna Commercial PPO 105.88 percent of total billed charges 105.88 163.63 55 of billed Charges SAW BLADE 6118-127-90 272 RC inpatient 210.88 105.44 BCBS Louisiana PPO 105.44 percent of total billed charges 105.44 179.25 50% of Eligible Charges SAW BLADE 6118-127-90 272 RC outpatient 210.88 168.7 BCBS Louisiana PPO 168.7 percent of total billed charges 115.98 179.25 80% of billed charge SAW BLADE 6118-127-90 272 RC outpatient 210.88 168.7 Cigna Commercial PPO 115.98 percent of total billed charges 115.98 179.25 55% of Billed Charges SAW BLADE 6118-127-90 272 RC inpatient 210.88 105.44 IMA of Louisiana Commercial PPO 179.25 percent of total billed charges 105.44 179.25 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 6118-127-90 272 RC outpatient 210.88 168.7 IMA of Louisiana Commercial PPO 179.25 percent of total billed charges 115.98 179.25 Reimbursement at 85% of billed charges SAW BLADE 6118-127-90 272 RC outpatient 210.88 168.7 Aetna Commercial PPO 115.98 percent of total billed charges 115.98 179.25 55 of billed Charges CONDOM CATHETER 272 RC inpatient 597.6 298.8 BCBS Louisiana PPO 298.8 percent of total billed charges 298.8 507.96 50% of Eligible Charges CONDOM CATHETER 272 RC outpatient 597.6 478.08 BCBS Louisiana PPO 478.08 percent of total billed charges 328.68 507.96 80% of billed charge CONDOM CATHETER 272 RC outpatient 597.6 478.08 Cigna Commercial PPO 328.68 percent of total billed charges 328.68 507.96 55% of Billed Charges CONDOM CATHETER 272 RC inpatient 597.6 298.8 IMA of Louisiana Commercial PPO 507.96 percent of total billed charges 298.8 507.96 Inpatient Reimbursement at 85% of Billed Charges CONDOM CATHETER 272 RC outpatient 597.6 478.08 IMA of Louisiana Commercial PPO 507.96 percent of total billed charges 328.68 507.96 Reimbursement at 85% of billed charges CONDOM CATHETER 272 RC outpatient 597.6 478.08 Aetna Commercial PPO 328.68 percent of total billed charges 328.68 507.96 55 of billed Charges NEEDLE KEITH #2 LONG 272 RC inpatient 699.69 349.85 BCBS Louisiana PPO 349.85 percent of total billed charges 349.85 594.74 50% of Eligible Charges NEEDLE KEITH #2 LONG 272 RC outpatient 699.69 559.75 BCBS Louisiana PPO 559.75 percent of total billed charges 384.83 594.74 80% of billed charge NEEDLE KEITH #2 LONG 272 RC outpatient 699.69 559.75 Cigna Commercial PPO 384.83 percent of total billed charges 384.83 594.74 55% of Billed Charges NEEDLE KEITH #2 LONG 272 RC inpatient 699.69 349.85 IMA of Louisiana Commercial PPO 594.74 percent of total billed charges 349.85 594.74 Inpatient Reimbursement at 85% of Billed Charges NEEDLE KEITH #2 LONG 272 RC outpatient 699.69 559.75 IMA of Louisiana Commercial PPO 594.74 percent of total billed charges 384.83 594.74 Reimbursement at 85% of billed charges NEEDLE KEITH #2 LONG 272 RC outpatient 699.69 559.75 Aetna Commercial PPO 384.83 percent of total billed charges 384.83 594.74 55 of billed Charges K - WIRE 2.0MM 150MM - SYNTHES 272 RC inpatient 302.4 151.2 BCBS Louisiana PPO 151.2 percent of total billed charges 151.2 257.04 50% of Eligible Charges K - WIRE 2.0MM 150MM - SYNTHES 272 RC outpatient 302.4 241.92 BCBS Louisiana PPO 241.92 percent of total billed charges 166.32 257.04 80% of billed charge K - WIRE 2.0MM 150MM - SYNTHES 272 RC outpatient 302.4 241.92 Cigna Commercial PPO 166.32 percent of total billed charges 166.32 257.04 55% of Billed Charges K - WIRE 2.0MM 150MM - SYNTHES 272 RC inpatient 302.4 151.2 IMA of Louisiana Commercial PPO 257.04 percent of total billed charges 151.2 257.04 Inpatient Reimbursement at 85% of Billed Charges K - WIRE 2.0MM 150MM - SYNTHES 272 RC outpatient 302.4 241.92 IMA of Louisiana Commercial PPO 257.04 percent of total billed charges 166.32 257.04 Reimbursement at 85% of billed charges K - WIRE 2.0MM 150MM - SYNTHES 272 RC outpatient 302.4 241.92 Aetna Commercial PPO 166.32 percent of total billed charges 166.32 257.04 55 of billed Charges SAW BLADE 2108-156 272 RC inpatient 108.15 54.08 BCBS Louisiana PPO 54.08 percent of total billed charges 54.08 91.93 50% of Eligible Charges SAW BLADE 2108-156 272 RC outpatient 108.15 86.52 BCBS Louisiana PPO 86.52 percent of total billed charges 59.48 91.93 80% of billed charge SAW BLADE 2108-156 272 RC outpatient 108.15 86.52 Cigna Commercial PPO 59.48 percent of total billed charges 59.48 91.93 55% of Billed Charges SAW BLADE 2108-156 272 RC inpatient 108.15 54.08 IMA of Louisiana Commercial PPO 91.93 percent of total billed charges 54.08 91.93 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-156 272 RC outpatient 108.15 86.52 IMA of Louisiana Commercial PPO 91.93 percent of total billed charges 59.48 91.93 Reimbursement at 85% of billed charges SAW BLADE 2108-156 272 RC outpatient 108.15 86.52 Aetna Commercial PPO 59.48 percent of total billed charges 59.48 91.93 55 of billed Charges SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC inpatient 2059.06 1029.53 BCBS Louisiana PPO 1029.53 percent of total billed charges 1029.53 1750.2 50% of Eligible Charges SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC outpatient 2059.06 1647.25 BCBS Louisiana PPO 1647.25 percent of total billed charges 761.85 1750.2 80% of billed charge SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC outpatient 2059.06 1647.25 Cigna Commercial PPO 1194.25 percent of total billed charges 761.85 1750.2 58% of Billed Charges/$500 Threshold SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC inpatient 2059.06 1029.53 IMA of Louisiana Commercial PPO 1750.2 percent of total billed charges 1029.53 1750.2 Inpatient Reimbursement at 85% of Billed Charges SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC outpatient 2059.06 1647.25 IMA of Louisiana Commercial PPO 1750.2 percent of total billed charges 761.85 1750.2 Reimbursement at 85% of billed charges SUBCHONDROPLASTY CONV. KIT - ZIMMER C1713 HCPCS 278 RC outpatient 2059.06 1647.25 Aetna Commercial PPO 761.85 percent of total billed charges 761.85 1750.2 37% Of Billed Charges 2000 SYRINGE 30CC LL 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges SYRINGE 30CC LL 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge SYRINGE 30CC LL 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges SYRINGE 30CC LL 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 30CC LL 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges SYRINGE 30CC LL 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUCTION RING - BLACK HOLE - STRYKER 272 RC inpatient 603.75 301.88 BCBS Louisiana PPO 301.88 percent of total billed charges 301.88 513.19 50% of Eligible Charges SUCTION RING - BLACK HOLE - STRYKER 272 RC outpatient 603.75 483 BCBS Louisiana PPO 483 percent of total billed charges 332.06 513.19 80% of billed charge SUCTION RING - BLACK HOLE - STRYKER 272 RC outpatient 603.75 483 Cigna Commercial PPO 332.06 percent of total billed charges 332.06 513.19 55% of Billed Charges SUCTION RING - BLACK HOLE - STRYKER 272 RC inpatient 603.75 301.88 IMA of Louisiana Commercial PPO 513.19 percent of total billed charges 301.88 513.19 Inpatient Reimbursement at 85% of Billed Charges SUCTION RING - BLACK HOLE - STRYKER 272 RC outpatient 603.75 483 IMA of Louisiana Commercial PPO 513.19 percent of total billed charges 332.06 513.19 Reimbursement at 85% of billed charges SUCTION RING - BLACK HOLE - STRYKER 272 RC outpatient 603.75 483 Aetna Commercial PPO 332.06 percent of total billed charges 332.06 513.19 55 of billed Charges GLIDESCOPE GVL #4 STAT 272 RC inpatient 475.09 237.55 BCBS Louisiana PPO 237.55 percent of total billed charges 237.55 403.83 50% of Eligible Charges GLIDESCOPE GVL #4 STAT 272 RC outpatient 475.09 380.07 BCBS Louisiana PPO 380.07 percent of total billed charges 261.3 403.83 80% of billed charge GLIDESCOPE GVL #4 STAT 272 RC outpatient 475.09 380.07 Cigna Commercial PPO 261.3 percent of total billed charges 261.3 403.83 55% of Billed Charges GLIDESCOPE GVL #4 STAT 272 RC inpatient 475.09 237.55 IMA of Louisiana Commercial PPO 403.83 percent of total billed charges 237.55 403.83 Inpatient Reimbursement at 85% of Billed Charges GLIDESCOPE GVL #4 STAT 272 RC outpatient 475.09 380.07 IMA of Louisiana Commercial PPO 403.83 percent of total billed charges 261.3 403.83 Reimbursement at 85% of billed charges GLIDESCOPE GVL #4 STAT 272 RC outpatient 475.09 380.07 Aetna Commercial PPO 261.3 percent of total billed charges 261.3 403.83 55 of billed Charges SPINAL NEEDLE 25G X 5 #183A022 272 RC inpatient 636.95 318.48 BCBS Louisiana PPO 318.48 percent of total billed charges 318.48 541.41 50% of Eligible Charges SPINAL NEEDLE 25G X 5 #183A022 272 RC outpatient 636.95 509.56 BCBS Louisiana PPO 509.56 percent of total billed charges 350.32 541.41 80% of billed charge SPINAL NEEDLE 25G X 5 #183A022 272 RC outpatient 636.95 509.56 Cigna Commercial PPO 350.32 percent of total billed charges 350.32 541.41 55% of Billed Charges SPINAL NEEDLE 25G X 5 #183A022 272 RC inpatient 636.95 318.48 IMA of Louisiana Commercial PPO 541.41 percent of total billed charges 318.48 541.41 Inpatient Reimbursement at 85% of Billed Charges SPINAL NEEDLE 25G X 5 #183A022 272 RC outpatient 636.95 509.56 IMA of Louisiana Commercial PPO 541.41 percent of total billed charges 350.32 541.41 Reimbursement at 85% of billed charges SPINAL NEEDLE 25G X 5 #183A022 272 RC outpatient 636.95 509.56 Aetna Commercial PPO 350.32 percent of total billed charges 350.32 541.41 55 of billed Charges INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC inpatient 6825 3412.5 BCBS Louisiana PPO 3412.5 percent of total billed charges 3412.5 5801.25 50% of Eligible Charges INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC outpatient 6825 5460 BCBS Louisiana PPO 5460 percent of total billed charges 2525.25 5801.25 80% of billed charge INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC outpatient 6825 5460 Cigna Commercial PPO 3958.5 percent of total billed charges 2525.25 5801.25 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC inpatient 6825 3412.5 IMA of Louisiana Commercial PPO 5801.25 percent of total billed charges 3412.5 5801.25 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC outpatient 6825 5460 IMA of Louisiana Commercial PPO 5801.25 percent of total billed charges 2525.25 5801.25 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT MEDIUM-SHS PRODUCT C1713 HCPCS 278 RC outpatient 6825 5460 Aetna Commercial PPO 2525.25 percent of total billed charges 2525.25 5801.25 37% Of Billed Charges 2000 BIOPATCH IV DRESSING 272 RC inpatient 31.02 15.51 BCBS Louisiana PPO 15.51 percent of total billed charges 15.51 26.37 50% of Eligible Charges BIOPATCH IV DRESSING 272 RC outpatient 31.02 24.82 BCBS Louisiana PPO 24.82 percent of total billed charges 17.06 26.37 80% of billed charge BIOPATCH IV DRESSING 272 RC outpatient 31.02 24.82 Cigna Commercial PPO 17.06 percent of total billed charges 17.06 26.37 55% of Billed Charges BIOPATCH IV DRESSING 272 RC inpatient 31.02 15.51 IMA of Louisiana Commercial PPO 26.37 percent of total billed charges 15.51 26.37 Inpatient Reimbursement at 85% of Billed Charges BIOPATCH IV DRESSING 272 RC outpatient 31.02 24.82 IMA of Louisiana Commercial PPO 26.37 percent of total billed charges 17.06 26.37 Reimbursement at 85% of billed charges BIOPATCH IV DRESSING 272 RC outpatient 31.02 24.82 Aetna Commercial PPO 17.06 percent of total billed charges 17.06 26.37 55 of billed Charges BLANKET READY HEAT - ATCHISON 272 RC inpatient 400 200 BCBS Louisiana PPO 200 percent of total billed charges 200 340 50% of Eligible Charges BLANKET READY HEAT - ATCHISON 272 RC outpatient 400 320 BCBS Louisiana PPO 320 percent of total billed charges 220 340 80% of billed charge BLANKET READY HEAT - ATCHISON 272 RC outpatient 400 320 Cigna Commercial PPO 220 percent of total billed charges 220 340 55% of Billed Charges BLANKET READY HEAT - ATCHISON 272 RC inpatient 400 200 IMA of Louisiana Commercial PPO 340 percent of total billed charges 200 340 Inpatient Reimbursement at 85% of Billed Charges BLANKET READY HEAT - ATCHISON 272 RC outpatient 400 320 IMA of Louisiana Commercial PPO 340 percent of total billed charges 220 340 Reimbursement at 85% of billed charges BLANKET READY HEAT - ATCHISON 272 RC outpatient 400 320 Aetna Commercial PPO 220 percent of total billed charges 220 340 55 of billed Charges DRAIN PENROSE 1/2 - M HAYNIE 272 RC inpatient 148.93 74.47 BCBS Louisiana PPO 74.47 percent of total billed charges 74.47 126.59 50% of Eligible Charges DRAIN PENROSE 1/2 - M HAYNIE 272 RC outpatient 148.93 119.14 BCBS Louisiana PPO 119.14 percent of total billed charges 81.91 126.59 80% of billed charge DRAIN PENROSE 1/2 - M HAYNIE 272 RC outpatient 148.93 119.14 Cigna Commercial PPO 81.91 percent of total billed charges 81.91 126.59 55% of Billed Charges DRAIN PENROSE 1/2 - M HAYNIE 272 RC inpatient 148.93 74.47 IMA of Louisiana Commercial PPO 126.59 percent of total billed charges 74.47 126.59 Inpatient Reimbursement at 85% of Billed Charges DRAIN PENROSE 1/2 - M HAYNIE 272 RC outpatient 148.93 119.14 IMA of Louisiana Commercial PPO 126.59 percent of total billed charges 81.91 126.59 Reimbursement at 85% of billed charges DRAIN PENROSE 1/2 - M HAYNIE 272 RC outpatient 148.93 119.14 Aetna Commercial PPO 81.91 percent of total billed charges 81.91 126.59 55 of billed Charges BLADE SAW 5400-003-410 - M HAYNIE 272 RC inpatient 84 42 BCBS Louisiana PPO 42 percent of total billed charges 42 71.4 50% of Eligible Charges BLADE SAW 5400-003-410 - M HAYNIE 272 RC outpatient 84 67.2 BCBS Louisiana PPO 67.2 percent of total billed charges 46.2 71.4 80% of billed charge BLADE SAW 5400-003-410 - M HAYNIE 272 RC outpatient 84 67.2 Cigna Commercial PPO 46.2 percent of total billed charges 46.2 71.4 55% of Billed Charges BLADE SAW 5400-003-410 - M HAYNIE 272 RC inpatient 84 42 IMA of Louisiana Commercial PPO 71.4 percent of total billed charges 42 71.4 Inpatient Reimbursement at 85% of Billed Charges BLADE SAW 5400-003-410 - M HAYNIE 272 RC outpatient 84 67.2 IMA of Louisiana Commercial PPO 71.4 percent of total billed charges 46.2 71.4 Reimbursement at 85% of billed charges BLADE SAW 5400-003-410 - M HAYNIE 272 RC outpatient 84 67.2 Aetna Commercial PPO 46.2 percent of total billed charges 46.2 71.4 55 of billed Charges VIZADISC KNEE TRACKING KIT - MAKO 272 RC inpatient 481.5 240.75 BCBS Louisiana PPO 240.75 percent of total billed charges 240.75 409.28 50% of Eligible Charges VIZADISC KNEE TRACKING KIT - MAKO 272 RC outpatient 481.5 385.2 BCBS Louisiana PPO 385.2 percent of total billed charges 264.83 409.28 80% of billed charge VIZADISC KNEE TRACKING KIT - MAKO 272 RC outpatient 481.5 385.2 Cigna Commercial PPO 264.83 percent of total billed charges 264.83 409.28 55% of Billed Charges VIZADISC KNEE TRACKING KIT - MAKO 272 RC inpatient 481.5 240.75 IMA of Louisiana Commercial PPO 409.28 percent of total billed charges 240.75 409.28 Inpatient Reimbursement at 85% of Billed Charges VIZADISC KNEE TRACKING KIT - MAKO 272 RC outpatient 481.5 385.2 IMA of Louisiana Commercial PPO 409.28 percent of total billed charges 264.83 409.28 Reimbursement at 85% of billed charges VIZADISC KNEE TRACKING KIT - MAKO 272 RC outpatient 481.5 385.2 Aetna Commercial PPO 264.83 percent of total billed charges 264.83 409.28 55 of billed Charges BONE PIN 4 X 140MM - MAKO 272 RC inpatient 403.2 201.6 BCBS Louisiana PPO 201.6 percent of total billed charges 201.6 342.72 50% of Eligible Charges BONE PIN 4 X 140MM - MAKO 272 RC outpatient 403.2 322.56 BCBS Louisiana PPO 322.56 percent of total billed charges 221.76 342.72 80% of billed charge BONE PIN 4 X 140MM - MAKO 272 RC outpatient 403.2 322.56 Cigna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55% of Billed Charges BONE PIN 4 X 140MM - MAKO 272 RC inpatient 403.2 201.6 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 201.6 342.72 Inpatient Reimbursement at 85% of Billed Charges BONE PIN 4 X 140MM - MAKO 272 RC outpatient 403.2 322.56 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 221.76 342.72 Reimbursement at 85% of billed charges BONE PIN 4 X 140MM - MAKO 272 RC outpatient 403.2 322.56 Aetna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55 of billed Charges IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC inpatient 355.95 177.98 BCBS Louisiana PPO 177.98 percent of total billed charges 177.98 302.56 50% of Eligible Charges IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC outpatient 355.95 284.76 BCBS Louisiana PPO 284.76 percent of total billed charges 195.77 302.56 80% of billed charge IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC outpatient 355.95 284.76 Cigna Commercial PPO 195.77 percent of total billed charges 195.77 302.56 55% of Billed Charges IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC inpatient 355.95 177.98 IMA of Louisiana Commercial PPO 302.56 percent of total billed charges 177.98 302.56 Inpatient Reimbursement at 85% of Billed Charges IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC outpatient 355.95 284.76 IMA of Louisiana Commercial PPO 302.56 percent of total billed charges 195.77 302.56 Reimbursement at 85% of billed charges IRRIGATION TUBE ANSPACH EMAX 2 - MAKO 272 RC outpatient 355.95 284.76 Aetna Commercial PPO 195.77 percent of total billed charges 195.77 302.56 55 of billed Charges DEPENDS BRIEF - MEDIUM 270 RC inpatient 1.2 0.6 BCBS Louisiana PPO 0.6 percent of total billed charges 0.6 1.02 50% of Eligible Charges DEPENDS BRIEF - MEDIUM 270 RC outpatient 1.2 0.96 BCBS Louisiana PPO 0.96 percent of total billed charges 0.66 1.02 80% of billed charge DEPENDS BRIEF - MEDIUM 270 RC outpatient 1.2 0.96 Cigna Commercial PPO 0.66 percent of total billed charges 0.66 1.02 55% of Billed Charges DEPENDS BRIEF - MEDIUM 270 RC inpatient 1.2 0.6 IMA of Louisiana Commercial PPO 1.02 percent of total billed charges 0.6 1.02 Inpatient Reimbursement at 85% of Billed Charges DEPENDS BRIEF - MEDIUM 270 RC outpatient 1.2 0.96 IMA of Louisiana Commercial PPO 1.02 percent of total billed charges 0.66 1.02 Reimbursement at 85% of billed charges DEPENDS BRIEF - MEDIUM 270 RC outpatient 1.2 0.96 Aetna Commercial PPO 0.66 percent of total billed charges 0.66 1.02 55 of billed Charges DEPENDS BRIEF - LARGE 270 RC inpatient 1.52 0.76 BCBS Louisiana PPO 0.76 percent of total billed charges 0.76 1.29 50% of Eligible Charges DEPENDS BRIEF - LARGE 270 RC outpatient 1.52 1.22 BCBS Louisiana PPO 1.22 percent of total billed charges 0.84 1.29 80% of billed charge DEPENDS BRIEF - LARGE 270 RC outpatient 1.52 1.22 Cigna Commercial PPO 0.84 percent of total billed charges 0.84 1.29 55% of Billed Charges DEPENDS BRIEF - LARGE 270 RC inpatient 1.52 0.76 IMA of Louisiana Commercial PPO 1.29 percent of total billed charges 0.76 1.29 Inpatient Reimbursement at 85% of Billed Charges DEPENDS BRIEF - LARGE 270 RC outpatient 1.52 1.22 IMA of Louisiana Commercial PPO 1.29 percent of total billed charges 0.84 1.29 Reimbursement at 85% of billed charges DEPENDS BRIEF - LARGE 270 RC outpatient 1.52 1.22 Aetna Commercial PPO 0.84 percent of total billed charges 0.84 1.29 55 of billed Charges GLOVE LATEX FREE SZ 9 272 RC inpatient 6.52 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 3.26 5.54 50% of Eligible Charges GLOVE LATEX FREE SZ 9 272 RC outpatient 6.52 5.22 BCBS Louisiana PPO 5.22 percent of total billed charges 3.59 5.54 80% of billed charge GLOVE LATEX FREE SZ 9 272 RC outpatient 6.52 5.22 Cigna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55% of Billed Charges GLOVE LATEX FREE SZ 9 272 RC inpatient 6.52 3.26 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.26 5.54 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 9 272 RC outpatient 6.52 5.22 IMA of Louisiana Commercial PPO 5.54 percent of total billed charges 3.59 5.54 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 9 272 RC outpatient 6.52 5.22 Aetna Commercial PPO 3.59 percent of total billed charges 3.59 5.54 55 of billed Charges VIZADISC HIP PROCEDURE TRACK. KIT 272 RC inpatient 481.5 240.75 BCBS Louisiana PPO 240.75 percent of total billed charges 240.75 409.28 50% of Eligible Charges VIZADISC HIP PROCEDURE TRACK. KIT 272 RC outpatient 481.5 385.2 BCBS Louisiana PPO 385.2 percent of total billed charges 264.83 409.28 80% of billed charge VIZADISC HIP PROCEDURE TRACK. KIT 272 RC outpatient 481.5 385.2 Cigna Commercial PPO 264.83 percent of total billed charges 264.83 409.28 55% of Billed Charges VIZADISC HIP PROCEDURE TRACK. KIT 272 RC inpatient 481.5 240.75 IMA of Louisiana Commercial PPO 409.28 percent of total billed charges 240.75 409.28 Inpatient Reimbursement at 85% of Billed Charges VIZADISC HIP PROCEDURE TRACK. KIT 272 RC outpatient 481.5 385.2 IMA of Louisiana Commercial PPO 409.28 percent of total billed charges 264.83 409.28 Reimbursement at 85% of billed charges VIZADISC HIP PROCEDURE TRACK. KIT 272 RC outpatient 481.5 385.2 Aetna Commercial PPO 264.83 percent of total billed charges 264.83 409.28 55 of billed Charges DUET DRAINAGE BAG #46911 272 RC inpatient 128.35 64.18 BCBS Louisiana PPO 64.18 percent of total billed charges 64.18 109.1 50% of Eligible Charges DUET DRAINAGE BAG #46911 272 RC outpatient 128.35 102.68 BCBS Louisiana PPO 102.68 percent of total billed charges 70.59 109.1 80% of billed charge DUET DRAINAGE BAG #46911 272 RC outpatient 128.35 102.68 Cigna Commercial PPO 70.59 percent of total billed charges 70.59 109.1 55% of Billed Charges DUET DRAINAGE BAG #46911 272 RC inpatient 128.35 64.18 IMA of Louisiana Commercial PPO 109.1 percent of total billed charges 64.18 109.1 Inpatient Reimbursement at 85% of Billed Charges DUET DRAINAGE BAG #46911 272 RC outpatient 128.35 102.68 IMA of Louisiana Commercial PPO 109.1 percent of total billed charges 70.59 109.1 Reimbursement at 85% of billed charges DUET DRAINAGE BAG #46911 272 RC outpatient 128.35 102.68 Aetna Commercial PPO 70.59 percent of total billed charges 70.59 109.1 55 of billed Charges AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC inpatient 2850 1425 BCBS Louisiana PPO 1425 percent of total billed charges 1425 2422.5 50% of Eligible Charges AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC outpatient 2850 2280 BCBS Louisiana PPO 2280 percent of total billed charges 1054.5 2422.5 80% of billed charge AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC outpatient 2850 2280 Cigna Commercial PPO 1653 percent of total billed charges 1054.5 2422.5 58% of Billed Charges/$500 Threshold AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC inpatient 2850 1425 IMA of Louisiana Commercial PPO 2422.5 percent of total billed charges 1425 2422.5 Inpatient Reimbursement at 85% of Billed Charges AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC outpatient 2850 2280 IMA of Louisiana Commercial PPO 2422.5 percent of total billed charges 1054.5 2422.5 Reimbursement at 85% of billed charges AUGMENT BONE GRAFT 1.5CC - WRIGHT C1713 HCPCS 278 RC outpatient 2850 2280 Aetna Commercial PPO 1054.5 percent of total billed charges 1054.5 2422.5 37% Of Billed Charges 2000 NEEDLE CHIBA 25Gx8 272 RC inpatient 446.32 223.16 BCBS Louisiana PPO 223.16 percent of total billed charges 223.16 379.37 50% of Eligible Charges NEEDLE CHIBA 25Gx8 272 RC outpatient 446.32 357.06 BCBS Louisiana PPO 357.06 percent of total billed charges 245.48 379.37 80% of billed charge NEEDLE CHIBA 25Gx8 272 RC outpatient 446.32 357.06 Cigna Commercial PPO 245.48 percent of total billed charges 245.48 379.37 55% of Billed Charges NEEDLE CHIBA 25Gx8 272 RC inpatient 446.32 223.16 IMA of Louisiana Commercial PPO 379.37 percent of total billed charges 223.16 379.37 Inpatient Reimbursement at 85% of Billed Charges NEEDLE CHIBA 25Gx8 272 RC outpatient 446.32 357.06 IMA of Louisiana Commercial PPO 379.37 percent of total billed charges 245.48 379.37 Reimbursement at 85% of billed charges NEEDLE CHIBA 25Gx8 272 RC outpatient 446.32 357.06 Aetna Commercial PPO 245.48 percent of total billed charges 245.48 379.37 55 of billed Charges QUICK PRESSURE MONITOR SET 272 RC inpatient 993.75 496.88 BCBS Louisiana PPO 496.88 percent of total billed charges 496.88 844.69 50% of Eligible Charges QUICK PRESSURE MONITOR SET 272 RC outpatient 993.75 795 BCBS Louisiana PPO 795 percent of total billed charges 546.56 844.69 80% of billed charge QUICK PRESSURE MONITOR SET 272 RC outpatient 993.75 795 Cigna Commercial PPO 546.56 percent of total billed charges 546.56 844.69 55% of Billed Charges QUICK PRESSURE MONITOR SET 272 RC inpatient 993.75 496.88 IMA of Louisiana Commercial PPO 844.69 percent of total billed charges 496.88 844.69 Inpatient Reimbursement at 85% of Billed Charges QUICK PRESSURE MONITOR SET 272 RC outpatient 993.75 795 IMA of Louisiana Commercial PPO 844.69 percent of total billed charges 546.56 844.69 Reimbursement at 85% of billed charges QUICK PRESSURE MONITOR SET 272 RC outpatient 993.75 795 Aetna Commercial PPO 546.56 percent of total billed charges 546.56 844.69 55 of billed Charges BUR BALL 4MM #14BA40 272 RC inpatient 380.1 190.05 BCBS Louisiana PPO 190.05 percent of total billed charges 190.05 323.09 50% of Eligible Charges BUR BALL 4MM #14BA40 272 RC outpatient 380.1 304.08 BCBS Louisiana PPO 304.08 percent of total billed charges 209.06 323.09 80% of billed charge BUR BALL 4MM #14BA40 272 RC outpatient 380.1 304.08 Cigna Commercial PPO 209.06 percent of total billed charges 209.06 323.09 55% of Billed Charges BUR BALL 4MM #14BA40 272 RC inpatient 380.1 190.05 IMA of Louisiana Commercial PPO 323.09 percent of total billed charges 190.05 323.09 Inpatient Reimbursement at 85% of Billed Charges BUR BALL 4MM #14BA40 272 RC outpatient 380.1 304.08 IMA of Louisiana Commercial PPO 323.09 percent of total billed charges 209.06 323.09 Reimbursement at 85% of billed charges BUR BALL 4MM #14BA40 272 RC outpatient 380.1 304.08 Aetna Commercial PPO 209.06 percent of total billed charges 209.06 323.09 55 of billed Charges ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC inpatient 525 262.5 BCBS Louisiana PPO 262.5 percent of total billed charges 262.5 446.25 50% of Eligible Charges ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC outpatient 525 420 BCBS Louisiana PPO 420 percent of total billed charges 194.25 446.25 80% of billed charge ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC outpatient 525 420 Cigna Commercial PPO 304.5 percent of total billed charges 194.25 446.25 58% of Billed Charges/$500 Threshold ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC inpatient 525 262.5 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 262.5 446.25 Inpatient Reimbursement at 85% of Billed Charges ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC outpatient 525 420 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 194.25 446.25 Reimbursement at 85% of billed charges ANCHOR MULTIFIX S-ULTRA #72290001 C1713 HCPCS 278 RC outpatient 525 420 Aetna Commercial PPO 194.25 percent of total billed charges 194.25 446.25 37% Of Billed Charges 2000 PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC inpatient 437.5 218.75 BCBS Louisiana PPO 218.75 percent of total billed charges 218.75 371.88 50% of Eligible Charges PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC outpatient 437.5 350 BCBS Louisiana PPO 350 percent of total billed charges 161.88 371.88 80% of billed charge PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC outpatient 437.5 350 Cigna Commercial PPO 253.75 percent of total billed charges 161.88 371.88 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC inpatient 437.5 218.75 IMA of Louisiana Commercial PPO 371.88 percent of total billed charges 218.75 371.88 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC outpatient 437.5 350 IMA of Louisiana Commercial PPO 371.88 percent of total billed charges 161.88 371.88 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR W/ 3 HOLE - SYN C1713 HCPCS 278 RC outpatient 437.5 350 Aetna Commercial PPO 161.88 percent of total billed charges 161.88 371.88 37% Of Billed Charges 2000 DRESSING OPSITE 4X14 272 RC inpatient 38.64 19.32 BCBS Louisiana PPO 19.32 percent of total billed charges 19.32 32.84 50% of Eligible Charges DRESSING OPSITE 4X14 272 RC outpatient 38.64 30.91 BCBS Louisiana PPO 30.91 percent of total billed charges 21.25 32.84 80% of billed charge DRESSING OPSITE 4X14 272 RC outpatient 38.64 30.91 Cigna Commercial PPO 21.25 percent of total billed charges 21.25 32.84 55% of Billed Charges DRESSING OPSITE 4X14 272 RC inpatient 38.64 19.32 IMA of Louisiana Commercial PPO 32.84 percent of total billed charges 19.32 32.84 Inpatient Reimbursement at 85% of Billed Charges DRESSING OPSITE 4X14 272 RC outpatient 38.64 30.91 IMA of Louisiana Commercial PPO 32.84 percent of total billed charges 21.25 32.84 Reimbursement at 85% of billed charges DRESSING OPSITE 4X14 272 RC outpatient 38.64 30.91 Aetna Commercial PPO 21.25 percent of total billed charges 21.25 32.84 55 of billed Charges SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC inpatient 559.65 279.83 BCBS Louisiana PPO 279.83 percent of total billed charges 279.83 475.7 50% of Eligible Charges SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC outpatient 559.65 447.72 BCBS Louisiana PPO 447.72 percent of total billed charges 307.81 475.7 80% of billed charge SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC outpatient 559.65 447.72 Cigna Commercial PPO 307.81 percent of total billed charges 307.81 475.7 55% of Billed Charges SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC inpatient 559.65 279.83 IMA of Louisiana Commercial PPO 475.7 percent of total billed charges 279.83 475.7 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC outpatient 559.65 447.72 IMA of Louisiana Commercial PPO 475.7 percent of total billed charges 307.81 475.7 Reimbursement at 85% of billed charges SUTURE STRATFIX PDS CT-1 #SXPP1A443 272 RC outpatient 559.65 447.72 Aetna Commercial PPO 307.81 percent of total billed charges 307.81 475.7 55 of billed Charges OR SERVICES LEVEL 1 360 RC inpatient 750 375 BCBS Louisiana PPO 375 percent of total billed charges 375 637.5 50% of Eligible Charges OR SERVICES LEVEL 1 360 RC outpatient 750 600 BCBS Louisiana PPO 600 percent of total billed charges 412.5 637.5 80% of billed charge OR SERVICES LEVEL 1 360 RC outpatient 750 600 Cigna Commercial PPO 412.5 percent of total billed charges 412.5 637.5 55% of Billed Charges OR SERVICES LEVEL 1 360 RC inpatient 750 375 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 375 637.5 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 1 360 RC outpatient 750 600 IMA of Louisiana Commercial PPO 637.5 percent of total billed charges 412.5 637.5 Reimbursement at 85% of billed charges OR SERVICES LEVEL 1 360 RC outpatient 750 600 Aetna Commercial PPO 412.5 percent of total billed charges 412.5 637.5 55 of billed Charges OR SERVICES LEVEL 3 360 RC inpatient 2000 1000 BCBS Louisiana PPO 1000 percent of total billed charges 1000 1700 50% of Eligible Charges OR SERVICES LEVEL 3 360 RC outpatient 2000 1600 BCBS Louisiana PPO 1600 percent of total billed charges 1100 1700 80% of billed charge OR SERVICES LEVEL 3 360 RC outpatient 2000 1600 Cigna Commercial PPO 1100 percent of total billed charges 1100 1700 55% of Billed Charges OR SERVICES LEVEL 3 360 RC inpatient 2000 1000 IMA of Louisiana Commercial PPO 1700 percent of total billed charges 1000 1700 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 3 360 RC outpatient 2000 1600 IMA of Louisiana Commercial PPO 1700 percent of total billed charges 1100 1700 Reimbursement at 85% of billed charges OR SERVICES LEVEL 3 360 RC outpatient 2000 1600 Aetna Commercial PPO 1100 percent of total billed charges 1100 1700 55 of billed Charges OR SERVICES LEVEL 9 360 RC inpatient 20000 10000 BCBS Louisiana PPO 10000 percent of total billed charges 10000 17000 50% of Eligible Charges OR SERVICES LEVEL 9 360 RC outpatient 20000 16000 BCBS Louisiana PPO 16000 percent of total billed charges 11000 17000 80% of billed charge OR SERVICES LEVEL 9 360 RC outpatient 20000 16000 Cigna Commercial PPO 11000 percent of total billed charges 11000 17000 55% of Billed Charges OR SERVICES LEVEL 9 360 RC inpatient 20000 10000 IMA of Louisiana Commercial PPO 17000 percent of total billed charges 10000 17000 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 9 360 RC outpatient 20000 16000 IMA of Louisiana Commercial PPO 17000 percent of total billed charges 11000 17000 Reimbursement at 85% of billed charges OR SERVICES LEVEL 9 360 RC outpatient 20000 16000 Aetna Commercial PPO 11000 percent of total billed charges 11000 17000 55 of billed Charges PROC ROOM SERVICES 12 360 RC inpatient 2196 1098 BCBS Louisiana PPO 1098 percent of total billed charges 1098 1866.6 50% of Eligible Charges PROC ROOM SERVICES 12 360 RC outpatient 2196 1756.8 BCBS Louisiana PPO 1756.8 percent of total billed charges 1207.8 1866.6 80% of billed charge PROC ROOM SERVICES 12 360 RC outpatient 2196 1756.8 Cigna Commercial PPO 1207.8 percent of total billed charges 1207.8 1866.6 55% of Billed Charges PROC ROOM SERVICES 12 360 RC inpatient 2196 1098 IMA of Louisiana Commercial PPO 1866.6 percent of total billed charges 1098 1866.6 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 12 360 RC outpatient 2196 1756.8 IMA of Louisiana Commercial PPO 1866.6 percent of total billed charges 1207.8 1866.6 Reimbursement at 85% of billed charges PROC ROOM SERVICES 12 360 RC outpatient 2196 1756.8 Aetna Commercial PPO 1207.8 percent of total billed charges 1207.8 1866.6 55 of billed Charges PROC ROOM SERVICES 14 360 RC inpatient 2701 1350.5 BCBS Louisiana PPO 1350.5 percent of total billed charges 1350.5 2295.85 50% of Eligible Charges PROC ROOM SERVICES 14 360 RC outpatient 2701 2160.8 BCBS Louisiana PPO 2160.8 percent of total billed charges 1485.55 2295.85 80% of billed charge PROC ROOM SERVICES 14 360 RC outpatient 2701 2160.8 Cigna Commercial PPO 1485.55 percent of total billed charges 1485.55 2295.85 55% of Billed Charges PROC ROOM SERVICES 14 360 RC inpatient 2701 1350.5 IMA of Louisiana Commercial PPO 2295.85 percent of total billed charges 1350.5 2295.85 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 14 360 RC outpatient 2701 2160.8 IMA of Louisiana Commercial PPO 2295.85 percent of total billed charges 1485.55 2295.85 Reimbursement at 85% of billed charges PROC ROOM SERVICES 14 360 RC outpatient 2701 2160.8 Aetna Commercial PPO 1485.55 percent of total billed charges 1485.55 2295.85 55 of billed Charges PROC ROOM SERVICES 16 360 RC inpatient 3099 1549.5 BCBS Louisiana PPO 1549.5 percent of total billed charges 1549.5 2634.15 50% of Eligible Charges PROC ROOM SERVICES 16 360 RC outpatient 3099 2479.2 BCBS Louisiana PPO 2479.2 percent of total billed charges 1704.45 2634.15 80% of billed charge PROC ROOM SERVICES 16 360 RC outpatient 3099 2479.2 Cigna Commercial PPO 1704.45 percent of total billed charges 1704.45 2634.15 55% of Billed Charges PROC ROOM SERVICES 16 360 RC inpatient 3099 1549.5 IMA of Louisiana Commercial PPO 2634.15 percent of total billed charges 1549.5 2634.15 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 16 360 RC outpatient 3099 2479.2 IMA of Louisiana Commercial PPO 2634.15 percent of total billed charges 1704.45 2634.15 Reimbursement at 85% of billed charges PROC ROOM SERVICES 16 360 RC outpatient 3099 2479.2 Aetna Commercial PPO 1704.45 percent of total billed charges 1704.45 2634.15 55 of billed Charges PROC ROOM SERVICES 23 360 RC inpatient 4386 2193 BCBS Louisiana PPO 2193 percent of total billed charges 2193 3728.1 50% of Eligible Charges PROC ROOM SERVICES 23 360 RC outpatient 4386 3508.8 BCBS Louisiana PPO 3508.8 percent of total billed charges 2412.3 3728.1 80% of billed charge PROC ROOM SERVICES 23 360 RC outpatient 4386 3508.8 Cigna Commercial PPO 2412.3 percent of total billed charges 2412.3 3728.1 55% of Billed Charges PROC ROOM SERVICES 23 360 RC inpatient 4386 2193 IMA of Louisiana Commercial PPO 3728.1 percent of total billed charges 2193 3728.1 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 23 360 RC outpatient 4386 3508.8 IMA of Louisiana Commercial PPO 3728.1 percent of total billed charges 2412.3 3728.1 Reimbursement at 85% of billed charges PROC ROOM SERVICES 23 360 RC outpatient 4386 3508.8 Aetna Commercial PPO 2412.3 percent of total billed charges 2412.3 3728.1 55 of billed Charges PROC ROOM SERVICES 25 360 RC inpatient 4825 2412.5 BCBS Louisiana PPO 2412.5 percent of total billed charges 2412.5 4101.25 50% of Eligible Charges PROC ROOM SERVICES 25 360 RC outpatient 4825 3860 BCBS Louisiana PPO 3860 percent of total billed charges 2653.75 4101.25 80% of billed charge PROC ROOM SERVICES 25 360 RC outpatient 4825 3860 Cigna Commercial PPO 2653.75 percent of total billed charges 2653.75 4101.25 55% of Billed Charges PROC ROOM SERVICES 25 360 RC inpatient 4825 2412.5 IMA of Louisiana Commercial PPO 4101.25 percent of total billed charges 2412.5 4101.25 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 25 360 RC outpatient 4825 3860 IMA of Louisiana Commercial PPO 4101.25 percent of total billed charges 2653.75 4101.25 Reimbursement at 85% of billed charges PROC ROOM SERVICES 25 360 RC outpatient 4825 3860 Aetna Commercial PPO 2653.75 percent of total billed charges 2653.75 4101.25 55 of billed Charges REC RM .5HR 710 RC inpatient 525 262.5 BCBS Louisiana PPO 262.5 percent of total billed charges 262.5 446.25 50% of Eligible Charges REC RM .5HR 710 RC outpatient 525 420 BCBS Louisiana PPO 420 percent of total billed charges 288.75 446.25 80% of billed charge REC RM .5HR 710 RC outpatient 525 420 Cigna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55% of Billed Charges REC RM .5HR 710 RC inpatient 525 262.5 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 262.5 446.25 Inpatient Reimbursement at 85% of Billed Charges REC RM .5HR 710 RC outpatient 525 420 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 288.75 446.25 Reimbursement at 85% of billed charges REC RM .5HR 710 RC outpatient 525 420 Aetna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55 of billed Charges REC RM 1.5 HR 710 RC inpatient 1575 787.5 BCBS Louisiana PPO 787.5 percent of total billed charges 787.5 1338.75 50% of Eligible Charges REC RM 1.5 HR 710 RC outpatient 1575 1260 BCBS Louisiana PPO 1260 percent of total billed charges 866.25 1338.75 80% of billed charge REC RM 1.5 HR 710 RC outpatient 1575 1260 Cigna Commercial PPO 866.25 percent of total billed charges 866.25 1338.75 55% of Billed Charges REC RM 1.5 HR 710 RC inpatient 1575 787.5 IMA of Louisiana Commercial PPO 1338.75 percent of total billed charges 787.5 1338.75 Inpatient Reimbursement at 85% of Billed Charges REC RM 1.5 HR 710 RC outpatient 1575 1260 IMA of Louisiana Commercial PPO 1338.75 percent of total billed charges 866.25 1338.75 Reimbursement at 85% of billed charges REC RM 1.5 HR 710 RC outpatient 1575 1260 Aetna Commercial PPO 866.25 percent of total billed charges 866.25 1338.75 55 of billed Charges REC ROOM 5.5 HR 710 RC inpatient 5775 2887.5 BCBS Louisiana PPO 2887.5 percent of total billed charges 2887.5 4908.75 50% of Eligible Charges REC ROOM 5.5 HR 710 RC outpatient 5775 4620 BCBS Louisiana PPO 4620 percent of total billed charges 3176.25 4908.75 80% of billed charge REC ROOM 5.5 HR 710 RC outpatient 5775 4620 Cigna Commercial PPO 3176.25 percent of total billed charges 3176.25 4908.75 55% of Billed Charges REC ROOM 5.5 HR 710 RC inpatient 5775 2887.5 IMA of Louisiana Commercial PPO 4908.75 percent of total billed charges 2887.5 4908.75 Inpatient Reimbursement at 85% of Billed Charges REC ROOM 5.5 HR 710 RC outpatient 5775 4620 IMA of Louisiana Commercial PPO 4908.75 percent of total billed charges 3176.25 4908.75 Reimbursement at 85% of billed charges REC ROOM 5.5 HR 710 RC outpatient 5775 4620 Aetna Commercial PPO 3176.25 percent of total billed charges 3176.25 4908.75 55 of billed Charges HGB 85018 CPT 300 RC inpatient 7.33 3.67 BCBS Louisiana PPO 3.67 percent of total billed charges 3.67 6.23 50% of Eligible Charges HGB 85018 CPT 300 RC outpatient 7.33 5.13 BCBS Louisiana PPO 5.13 percent of total billed charges 4.03 7.76 70% of billed charges HGB 85018 CPT 300 RC outpatient 7.33 5.13 Cigna Commercial PPO 4.03 percent of total billed charges 4.03 7.76 55% of Billed Charges HGB 85018 CPT 300 RC inpatient 7.33 3.67 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 3.67 6.23 Inpatient Reimbursement at 85% of Billed Charges HGB 85018 CPT 300 RC outpatient 7.33 5.13 IMA of Louisiana Commercial PPO 6.23 percent of total billed charges 4.03 7.76 Reimbursement at 85% of billed charges HGB 85018 CPT 300 RC outpatient 7.33 5.13 Aetna Commercial PPO 7.76 fee schedule 4.03 7.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate POTASSIUM 84132 CPT 300 RC inpatient 14.63 7.32 BCBS Louisiana PPO 7.32 percent of total billed charges 7.32 12.44 50% of Eligible Charges POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 BCBS Louisiana PPO 10.24 percent of total billed charges 8.05 15.02 70% of billed charges POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 Cigna Commercial PPO 8.05 percent of total billed charges 8.05 15.02 55% of Billed Charges POTASSIUM 84132 CPT 300 RC inpatient 14.63 7.32 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 7.32 12.44 Inpatient Reimbursement at 85% of Billed Charges POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 IMA of Louisiana Commercial PPO 12.44 percent of total billed charges 8.05 15.02 Reimbursement at 85% of billed charges POTASSIUM 84132 CPT 300 RC outpatient 14.63 10.24 Aetna Commercial PPO 15.02 fee schedule 8.05 15.02 200% Of Aetna Market Fee Schedule Hospital Technical Rate SODIUM 84295 CPT 300 RC inpatient 14.85 7.43 BCBS Louisiana PPO 7.43 percent of total billed charges 7.43 12.62 50% of Eligible Charges SODIUM 84295 CPT 300 RC outpatient 14.85 10.4 BCBS Louisiana PPO 10.4 percent of total billed charges 8.17 15.74 70% of billed charges SODIUM 84295 CPT 300 RC outpatient 14.85 10.4 Cigna Commercial PPO 8.17 percent of total billed charges 8.17 15.74 55% of Billed Charges SODIUM 84295 CPT 300 RC inpatient 14.85 7.43 IMA of Louisiana Commercial PPO 12.62 percent of total billed charges 7.43 12.62 Inpatient Reimbursement at 85% of Billed Charges SODIUM 84295 CPT 300 RC outpatient 14.85 10.4 IMA of Louisiana Commercial PPO 12.62 percent of total billed charges 8.17 15.74 Reimbursement at 85% of billed charges SODIUM 84295 CPT 300 RC outpatient 14.85 10.4 Aetna Commercial PPO 15.74 fee schedule 8.17 15.74 200% Of Aetna Market Fee Schedule Hospital Technical Rate SEDIMENTATION RATE 85652 CPT 300 RC inpatient 8.33 4.17 BCBS Louisiana PPO 4.17 percent of total billed charges 4.17 7.08 50% of Eligible Charges SEDIMENTATION RATE 85652 CPT 300 RC outpatient 8.33 5.83 BCBS Louisiana PPO 5.83 percent of total billed charges 4.58 8.84 70% of billed charges SEDIMENTATION RATE 85652 CPT 300 RC outpatient 8.33 5.83 Cigna Commercial PPO 4.58 percent of total billed charges 4.58 8.84 55% of Billed Charges SEDIMENTATION RATE 85652 CPT 300 RC inpatient 8.33 4.17 IMA of Louisiana Commercial PPO 7.08 percent of total billed charges 4.17 7.08 Inpatient Reimbursement at 85% of Billed Charges SEDIMENTATION RATE 85652 CPT 300 RC outpatient 8.33 5.83 IMA of Louisiana Commercial PPO 7.08 percent of total billed charges 4.58 8.84 Reimbursement at 85% of billed charges SEDIMENTATION RATE 85652 CPT 300 RC outpatient 8.33 5.83 Aetna Commercial PPO 8.84 fee schedule 4.58 8.84 200% Of Aetna Market Fee Schedule Hospital Technical Rate TSH 84443 CPT 300 RC inpatient 51.88 25.94 BCBS Louisiana PPO 25.94 percent of total billed charges 25.94 44.1 50% of Eligible Charges TSH 84443 CPT 300 RC outpatient 51.88 36.32 BCBS Louisiana PPO 36.32 percent of total billed charges 28.53 54.94 70% of billed charges TSH 84443 CPT 300 RC outpatient 51.88 36.32 Cigna Commercial PPO 28.53 percent of total billed charges 28.53 54.94 55% of Billed Charges TSH 84443 CPT 300 RC inpatient 51.88 25.94 IMA of Louisiana Commercial PPO 44.1 percent of total billed charges 25.94 44.1 Inpatient Reimbursement at 85% of Billed Charges TSH 84443 CPT 300 RC outpatient 51.88 36.32 IMA of Louisiana Commercial PPO 44.1 percent of total billed charges 28.53 54.94 Reimbursement at 85% of billed charges TSH 84443 CPT 300 RC outpatient 51.88 36.32 Aetna Commercial PPO 54.94 fee schedule 28.53 54.94 200% Of Aetna Market Fee Schedule Hospital Technical Rate TYPE & SCREEN COMBO 86920 CPT 300 RC inpatient 322.95 161.48 BCBS Louisiana PPO 161.48 percent of total billed charges 161.48 274.51 50% of Eligible Charges TYPE & SCREEN COMBO 86920 CPT 300 RC outpatient 322.95 226.07 BCBS Louisiana PPO 226.07 percent of total billed charges 72.4 274.51 70% of billed charges TYPE & SCREEN COMBO 86920 CPT 300 RC outpatient 322.95 226.07 Cigna Commercial PPO 177.62 percent of total billed charges 72.4 274.51 55% of Billed Charges TYPE & SCREEN COMBO 86920 CPT 300 RC inpatient 322.95 161.48 IMA of Louisiana Commercial PPO 274.51 percent of total billed charges 161.48 274.51 Inpatient Reimbursement at 85% of Billed Charges TYPE & SCREEN COMBO 86920 CPT 300 RC outpatient 322.95 226.07 IMA of Louisiana Commercial PPO 274.51 percent of total billed charges 72.4 274.51 Reimbursement at 85% of billed charges TYPE & SCREEN COMBO 86920 CPT 300 RC outpatient 322.95 226.07 Aetna Commercial PPO 72.4 fee schedule 72.4 274.51 200% Of Aetna Market Fee Schedule Hospital Technical Rate C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 BCBS Louisiana PPO 7.99 percent of total billed charges 7.99 13.58 50% of Eligible Charges C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 8.79 16.92 70% of billed charges C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Cigna Commercial PPO 8.79 percent of total billed charges 8.79 16.92 55% of Billed Charges C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 7.99 13.58 Inpatient Reimbursement at 85% of Billed Charges C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 8.79 16.92 Reimbursement at 85% of billed charges C--REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Aetna Commercial PPO 16.92 fee schedule 8.79 16.92 200% Of Aetna Market Fee Schedule Hospital Technical Rate RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC inpatient 17.5 8.75 BCBS Louisiana PPO 8.75 percent of total billed charges 8.75 14.88 50% of Eligible Charges RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 BCBS Louisiana PPO 12.25 percent of total billed charges 9.63 18.56 70% of billed charges RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 Cigna Commercial PPO 9.63 percent of total billed charges 9.63 18.56 55% of Billed Charges RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC inpatient 17.5 8.75 IMA of Louisiana Commercial PPO 14.88 percent of total billed charges 8.75 14.88 Inpatient Reimbursement at 85% of Billed Charges RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 IMA of Louisiana Commercial PPO 14.88 percent of total billed charges 9.63 18.56 Reimbursement at 85% of billed charges RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 Aetna Commercial PPO 18.56 fee schedule 9.63 18.56 200% Of Aetna Market Fee Schedule Hospital Technical Rate PROGESTERONE 84144 CPT 300 RC inpatient 64.4 32.2 BCBS Louisiana PPO 32.2 percent of total billed charges 32.2 54.74 50% of Eligible Charges PROGESTERONE 84144 CPT 300 RC outpatient 64.4 45.08 BCBS Louisiana PPO 45.08 percent of total billed charges 35.42 68.2 70% of billed charges PROGESTERONE 84144 CPT 300 RC outpatient 64.4 45.08 Cigna Commercial PPO 35.42 percent of total billed charges 35.42 68.2 55% of Billed Charges PROGESTERONE 84144 CPT 300 RC inpatient 64.4 32.2 IMA of Louisiana Commercial PPO 54.74 percent of total billed charges 32.2 54.74 Inpatient Reimbursement at 85% of Billed Charges PROGESTERONE 84144 CPT 300 RC outpatient 64.4 45.08 IMA of Louisiana Commercial PPO 54.74 percent of total billed charges 35.42 68.2 Reimbursement at 85% of billed charges PROGESTERONE 84144 CPT 300 RC outpatient 64.4 45.08 Aetna Commercial PPO 68.2 fee schedule 35.42 68.2 200% Of Aetna Market Fee Schedule Hospital Technical Rate TRIGLYCERIDE 84478 CPT 300 RC inpatient 17.73 8.87 BCBS Louisiana PPO 8.87 percent of total billed charges 8.87 15.07 50% of Eligible Charges TRIGLYCERIDE 84478 CPT 300 RC outpatient 17.73 12.41 BCBS Louisiana PPO 12.41 percent of total billed charges 9.75 18.8 70% of billed charges TRIGLYCERIDE 84478 CPT 300 RC outpatient 17.73 12.41 Cigna Commercial PPO 9.75 percent of total billed charges 9.75 18.8 55% of Billed Charges TRIGLYCERIDE 84478 CPT 300 RC inpatient 17.73 8.87 IMA of Louisiana Commercial PPO 15.07 percent of total billed charges 8.87 15.07 Inpatient Reimbursement at 85% of Billed Charges TRIGLYCERIDE 84478 CPT 300 RC outpatient 17.73 12.41 IMA of Louisiana Commercial PPO 15.07 percent of total billed charges 9.75 18.8 Reimbursement at 85% of billed charges TRIGLYCERIDE 84478 CPT 300 RC outpatient 17.73 12.41 Aetna Commercial PPO 18.8 fee schedule 9.75 18.8 200% Of Aetna Market Fee Schedule Hospital Technical Rate LITHIUM 80178 CPT 301 RC inpatient 20.4 10.2 BCBS Louisiana PPO 10.2 percent of total billed charges 10.2 17.34 50% of Eligible Charges LITHIUM 80178 CPT 301 RC outpatient 20.4 14.28 BCBS Louisiana PPO 14.28 percent of total billed charges 11.22 21.62 70% of billed charges LITHIUM 80178 CPT 301 RC outpatient 20.4 14.28 Cigna Commercial PPO 11.22 percent of total billed charges 11.22 21.62 55% of Billed Charges LITHIUM 80178 CPT 301 RC inpatient 20.4 10.2 IMA of Louisiana Commercial PPO 17.34 percent of total billed charges 10.2 17.34 Inpatient Reimbursement at 85% of Billed Charges LITHIUM 80178 CPT 301 RC outpatient 20.4 14.28 IMA of Louisiana Commercial PPO 17.34 percent of total billed charges 11.22 21.62 Reimbursement at 85% of billed charges LITHIUM 80178 CPT 301 RC outpatient 20.4 14.28 Aetna Commercial PPO 21.62 fee schedule 11.22 21.62 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 BCBS Louisiana PPO 6.07 percent of total billed charges 6.07 10.31 50% of Eligible Charges prad_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 BCBS Louisiana PPO 8.49 percent of total billed charges 6.67 12.86 70% of billed charges prad_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Cigna Commercial PPO 6.67 percent of total billed charges 6.67 12.86 55% of Billed Charges prad_PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.07 10.31 Inpatient Reimbursement at 85% of Billed Charges prad_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.67 12.86 Reimbursement at 85% of billed charges prad_PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Aetna Commercial PPO 12.86 fee schedule 6.67 12.86 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_EKG OR ECG 93005 CPT 730 RC inpatient 139.9 69.95 BCBS Louisiana PPO 69.95 percent of total billed charges 69.95 118.92 50% of Eligible Charges prad_EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 BCBS Louisiana PPO 111.92 percent of total billed charges 10.83 118.92 80% of billed charge prad_EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 Cigna Commercial PPO 76.95 percent of total billed charges 10.83 118.92 55% of Billed Charges prad_EKG OR ECG 93005 CPT 730 RC inpatient 139.9 69.95 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 69.95 118.92 Inpatient Reimbursement at 85% of Billed Charges prad_EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 10.83 118.92 Reimbursement at 85% of billed charges prad_EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 Aetna Commercial PPO 10.83 fee schedule 10.83 118.92 100 of Aetna Market Fee Schedule prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC inpatient 108.33 54.17 BCBS Louisiana PPO 54.17 percent of total billed charges 54.17 92.08 50% of Eligible Charges prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 BCBS Louisiana PPO 75.83 percent of total billed charges 59.58 114.72 70% of billed charges prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 Cigna Commercial PPO 59.58 percent of total billed charges 59.58 114.72 55% of Billed Charges prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC inpatient 108.33 54.17 IMA of Louisiana Commercial PPO 92.08 percent of total billed charges 54.17 92.08 Inpatient Reimbursement at 85% of Billed Charges prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 IMA of Louisiana Commercial PPO 92.08 percent of total billed charges 59.58 114.72 Reimbursement at 85% of billed charges prad_MRSA/MSSA NASAL SCREEN PCR 87641 CPT 300 RC outpatient 108.33 75.83 Aetna Commercial PPO 114.72 fee schedule 59.58 114.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_PLATELET COUNT 85049 CPT 300 RC inpatient 13.83 6.92 BCBS Louisiana PPO 6.92 percent of total billed charges 6.92 11.76 50% of Eligible Charges inpt3_PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 BCBS Louisiana PPO 9.68 percent of total billed charges 7.61 13.46 70% of billed charges inpt3_PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 Cigna Commercial PPO 7.61 percent of total billed charges 7.61 13.46 55% of Billed Charges inpt3_PLATELET COUNT 85049 CPT 300 RC inpatient 13.83 6.92 IMA of Louisiana Commercial PPO 11.76 percent of total billed charges 6.92 11.76 Inpatient Reimbursement at 85% of Billed Charges inpt3_PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 IMA of Louisiana Commercial PPO 11.76 percent of total billed charges 7.61 13.46 Reimbursement at 85% of billed charges inpt3_PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 Aetna Commercial PPO 13.46 fee schedule 7.61 13.46 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_ MAGNESIUM 83735 CPT 300 RC inpatient 28.48 14.24 BCBS Louisiana PPO 14.24 percent of total billed charges 14.24 24.21 50% of Eligible Charges inpt3_ MAGNESIUM 83735 CPT 300 RC outpatient 28.48 19.94 BCBS Louisiana PPO 19.94 percent of total billed charges 15.66 24.21 70% of billed charges inpt3_ MAGNESIUM 83735 CPT 300 RC outpatient 28.48 19.94 Cigna Commercial PPO 15.66 percent of total billed charges 15.66 24.21 55% of Billed Charges inpt3_ MAGNESIUM 83735 CPT 300 RC inpatient 28.48 14.24 IMA of Louisiana Commercial PPO 24.21 percent of total billed charges 14.24 24.21 Inpatient Reimbursement at 85% of Billed Charges inpt3_ MAGNESIUM 83735 CPT 300 RC outpatient 28.48 19.94 IMA of Louisiana Commercial PPO 24.21 percent of total billed charges 15.66 24.21 Reimbursement at 85% of billed charges inpt3_ MAGNESIUM 83735 CPT 300 RC outpatient 28.48 19.94 Aetna Commercial PPO 21.88 fee schedule 15.66 24.21 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 BCBS Louisiana PPO 14.99 percent of total billed charges 14.99 25.48 50% of Eligible Charges inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 BCBS Louisiana PPO 20.99 percent of total billed charges 16.49 31.72 70% of billed charges inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Cigna Commercial PPO 16.49 percent of total billed charges 16.49 31.72 55% of Billed Charges inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 14.99 25.48 Inpatient Reimbursement at 85% of Billed Charges inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 16.49 31.72 Reimbursement at 85% of billed charges inpt3_ HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Aetna Commercial PPO 31.72 fee schedule 16.49 31.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC inpatient 17.5 8.75 BCBS Louisiana PPO 8.75 percent of total billed charges 8.75 14.88 50% of Eligible Charges prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 BCBS Louisiana PPO 12.25 percent of total billed charges 9.63 18.56 70% of billed charges prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 Cigna Commercial PPO 9.63 percent of total billed charges 9.63 18.56 55% of Billed Charges prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC inpatient 17.5 8.75 IMA of Louisiana Commercial PPO 14.88 percent of total billed charges 8.75 14.88 Inpatient Reimbursement at 85% of Billed Charges prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 IMA of Louisiana Commercial PPO 14.88 percent of total billed charges 9.63 18.56 Reimbursement at 85% of billed charges prad_RHEUMATOID ARTHRITIS (RA) 86430 CPT 302 RC outpatient 17.5 12.25 Aetna Commercial PPO 18.56 fee schedule 9.63 18.56 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 BCBS Louisiana PPO 6.98 percent of total billed charges 6.98 11.86 50% of Eligible Charges prad_URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 BCBS Louisiana PPO 9.77 percent of total billed charges 7.67 14.78 70% of billed charges prad_URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Cigna Commercial PPO 7.67 percent of total billed charges 7.67 14.78 55% of Billed Charges prad_URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 6.98 11.86 Inpatient Reimbursement at 85% of Billed Charges prad_URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 7.67 14.78 Reimbursement at 85% of billed charges prad_URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Aetna Commercial PPO 14.78 fee schedule 7.67 14.78 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_URINE CULTURE - LABCORP 87086 CPT 300 RC inpatient 24.9 12.45 BCBS Louisiana PPO 12.45 percent of total billed charges 12.45 21.17 50% of Eligible Charges prad_URINE CULTURE - LABCORP 87086 CPT 300 RC outpatient 24.9 17.43 BCBS Louisiana PPO 17.43 percent of total billed charges 13.7 26.4 70% of billed charges prad_URINE CULTURE - LABCORP 87086 CPT 300 RC outpatient 24.9 17.43 Cigna Commercial PPO 13.7 percent of total billed charges 13.7 26.4 55% of Billed Charges prad_URINE CULTURE - LABCORP 87086 CPT 300 RC inpatient 24.9 12.45 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 12.45 21.17 Inpatient Reimbursement at 85% of Billed Charges prad_URINE CULTURE - LABCORP 87086 CPT 300 RC outpatient 24.9 17.43 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 13.7 26.4 Reimbursement at 85% of billed charges prad_URINE CULTURE - LABCORP 87086 CPT 300 RC outpatient 24.9 17.43 Aetna Commercial PPO 26.4 fee schedule 13.7 26.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT ANKLE 2 VIEWS 73600 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HIP COMPLETE 73502 CPT 320 RC inpatient 265 132.5 BCBS Louisiana PPO 132.5 percent of total billed charges 132.5 225.25 50% of Eligible Charges XRAY DX RT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 BCBS Louisiana PPO 185.5 percent of total billed charges 145.75 700 70% of billed charges XRAY DX RT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 Cigna Commercial PPO 145.75 percent of total billed charges 145.75 700 55% of Billed Charges XRAY DX RT HIP COMPLETE 73502 CPT 320 RC inpatient 265 132.5 IMA of Louisiana Commercial PPO 225.25 percent of total billed charges 132.5 225.25 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 IMA of Louisiana Commercial PPO 225.25 percent of total billed charges 145.75 700 Reimbursement at 85% of billed charges XRAY DX RT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 Aetna Commercial PPO 700 case rate 145.75 700 700 Per Code Per DOS Paid In Addition XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT ANKLE 2 VIEWS 73600 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT ELBOW 3 VIEWS 73080 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HIP COMPLETE 73502 CPT 320 RC inpatient 265 132.5 BCBS Louisiana PPO 132.5 percent of total billed charges 132.5 225.25 50% of Eligible Charges XRAY DX LT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 BCBS Louisiana PPO 185.5 percent of total billed charges 145.75 700 70% of billed charges XRAY DX LT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 Cigna Commercial PPO 145.75 percent of total billed charges 145.75 700 55% of Billed Charges XRAY DX LT HIP COMPLETE 73502 CPT 320 RC inpatient 265 132.5 IMA of Louisiana Commercial PPO 225.25 percent of total billed charges 132.5 225.25 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 IMA of Louisiana Commercial PPO 225.25 percent of total billed charges 145.75 700 Reimbursement at 85% of billed charges XRAY DX LT HIP COMPLETE 73502 CPT 320 RC outpatient 265 185.5 Aetna Commercial PPO 700 case rate 145.75 700 700 Per Code Per DOS Paid In Addition XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT SHOULDER 2 VIEWS 73030 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI OF BRAIN WITHOUT CONTRAST 70540 CPT 611 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX ABDOMEN 3 OR MORE VIEWS 74021 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 BCBS Louisiana PPO 228.92 percent of total billed charges 124.21 243.23 80% of billed charge RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 Cigna Commercial PPO 157.38 percent of total billed charges 124.21 243.23 55% of Billed Charges RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 124.21 243.23 Reimbursement at 85% of billed charges RT.LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 Aetna Commercial PPO 124.21 fee schedule 124.21 243.23 100 Of Aetna Market Fee Schedule LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 BCBS Louisiana PPO 228.92 percent of total billed charges 124.21 243.23 80% of billed charge LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 Cigna Commercial PPO 157.38 percent of total billed charges 124.21 243.23 55% of Billed Charges LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 124.21 243.23 Reimbursement at 85% of billed charges LT LOWER EXT. VEN. ULTRASOUND 93971 CPT 402 RC outpatient 286.15 228.92 Aetna Commercial PPO 124.21 fee schedule 124.21 243.23 100 Of Aetna Market Fee Schedule CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 319.43 700 70% of billed charges CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC outpatient 580.78 406.55 Cigna Commercial PPO 319.43 percent of total billed charges 319.43 700 55% of Billed Charges CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 319.43 700 Reimbursement at 85% of billed charges CT ABD & PELV W/O CONTRAST 74176 CPT 320 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 319.43 700 700 Per Code Per DOS Paid In Addition GELFOAM SPONGE 50 250 RC 0000903230 NDC inpatient 1 EA 253 126.5 BCBS Louisiana PPO 126.5 percent of total billed charges 126.5 215.05 50% of Eligible Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 BCBS Louisiana PPO 202.4 percent of total billed charges 139.15 215.05 80% of billed charge GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 Cigna Commercial PPO 139.15 percent of total billed charges 139.15 215.05 55% of Billed Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC inpatient 1 EA 253 126.5 IMA of Louisiana Commercial PPO 215.05 percent of total billed charges 126.5 215.05 Inpatient Reimbursement at 85% of Billed Charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 IMA of Louisiana Commercial PPO 215.05 percent of total billed charges 139.15 215.05 Reimbursement at 85% of billed charges GELFOAM SPONGE 50 250 RC 0000903230 NDC outpatient 1 EA 253 202.4 Aetna Commercial PPO 139.15 percent of total billed charges 139.15 215.05 55 of billed Charges CARMEX .15OZ 250 RC 8307812317 NDC inpatient 1 EA 6.1 3.05 BCBS Louisiana PPO 3.05 percent of total billed charges 3.05 5.19 50% of Eligible Charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 BCBS Louisiana PPO 4.88 percent of total billed charges 3.36 5.19 80% of billed charge CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 Cigna Commercial PPO 3.36 percent of total billed charges 3.36 5.19 55% of Billed Charges CARMEX .15OZ 250 RC 8307812317 NDC inpatient 1 EA 6.1 3.05 IMA of Louisiana Commercial PPO 5.19 percent of total billed charges 3.05 5.19 Inpatient Reimbursement at 85% of Billed Charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 IMA of Louisiana Commercial PPO 5.19 percent of total billed charges 3.36 5.19 Reimbursement at 85% of billed charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 Aetna Commercial PPO 3.36 percent of total billed charges 3.36 5.19 55 of billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC inpatient 1 EA 3.06 1.53 BCBS Louisiana PPO 1.53 percent of total billed charges 1.53 2.6 50% of Eligible Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 BCBS Louisiana PPO 2.45 percent of total billed charges 1.68 2.6 80% of billed charge K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 Cigna Commercial PPO 1.68 percent of total billed charges 1.68 2.6 55% of Billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC inpatient 1 EA 3.06 1.53 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.53 2.6 Inpatient Reimbursement at 85% of Billed Charges K-PHOS NEUTRAL TAB NON-FORMULARY J8499 HCPCS 250 RC 0486111101 NDC outpatient 1 EA 3.06 2.45 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.68 2.6 Reimbursement at 85% of billed charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC inpatient 1 EA 5.33 2.67 BCBS Louisiana PPO 2.67 percent of total billed charges 2.67 4.53 50% of Eligible Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 BCBS Louisiana PPO 4.26 percent of total billed charges 2.93 4.53 80% of billed charge MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 Cigna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55% of Billed Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC inpatient 1 EA 5.33 2.67 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.67 4.53 Inpatient Reimbursement at 85% of Billed Charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 IMA of Louisiana Commercial PPO 4.53 percent of total billed charges 2.93 4.53 Reimbursement at 85% of billed charges MIRALAX SINGLE DOSE PACKET 250 RC 1152372680 NDC outpatient 1 EA 5.33 4.26 Aetna Commercial PPO 2.93 percent of total billed charges 2.93 4.53 55 of billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC inpatient 1 EA 12.3 6.15 BCBS Louisiana PPO 6.15 percent of total billed charges 6.15 10.46 50% of Eligible Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 BCBS Louisiana PPO 9.84 percent of total billed charges 6.77 10.46 80% of billed charge BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 Cigna Commercial PPO 6.77 percent of total billed charges 6.77 10.46 55% of Billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC inpatient 1 EA 12.3 6.15 IMA of Louisiana Commercial PPO 10.46 percent of total billed charges 6.15 10.46 Inpatient Reimbursement at 85% of Billed Charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 IMA of Louisiana Commercial PPO 10.46 percent of total billed charges 6.77 10.46 Reimbursement at 85% of billed charges BACTROBAN 2% NASAL OINTMENT 250 RC 5026856815 NDC outpatient 1 EA 12.3 9.84 Aetna Commercial PPO 6.77 percent of total billed charges 6.77 10.46 55 of billed Charges COMBIVENT 100MCG INHALER J7799 HCPCS 250 RC 0597002402 NDC inpatient 100 UN 2467.69 1233.85 BCBS Louisiana PPO 1233.85 percent of total billed charges 1233.85 2097.54 50% of Eligible Charges COMBIVENT 100MCG INHALER J7799 HCPCS 250 RC 0597002402 NDC outpatient 100 UN 2467.69 1974.15 BCBS Louisiana PPO 1974.15 percent of total billed charges 1357.23 2097.54 80% of billed charge COMBIVENT 100MCG INHALER J7799 HCPCS 250 RC 0597002402 NDC outpatient 100 UN 2467.69 1974.15 Cigna Commercial PPO 1357.23 percent of total billed charges 1357.23 2097.54 55% of Billed Charges COMBIVENT 100MCG INHALER J7799 HCPCS 250 RC 0597002402 NDC inpatient 100 UN 2467.69 1233.85 IMA of Louisiana Commercial PPO 2097.54 percent of total billed charges 1233.85 2097.54 Inpatient Reimbursement at 85% of Billed Charges COMBIVENT 100MCG INHALER J7799 HCPCS 250 RC 0597002402 NDC outpatient 100 UN 2467.69 1974.15 IMA of Louisiana Commercial PPO 2097.54 percent of total billed charges 1357.23 2097.54 Reimbursement at 85% of billed charges LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC inpatient 3.5 GR 52.7 26.35 BCBS Louisiana PPO 26.35 percent of total billed charges 26.35 44.8 50% of Eligible Charges LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC outpatient 3.5 GR 52.7 42.16 BCBS Louisiana PPO 42.16 percent of total billed charges 28.99 44.8 80% of billed charge LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC outpatient 3.5 GR 52.7 42.16 Cigna Commercial PPO 28.99 percent of total billed charges 28.99 44.8 55% of Billed Charges LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC inpatient 3.5 GR 52.7 26.35 IMA of Louisiana Commercial PPO 44.8 percent of total billed charges 26.35 44.8 Inpatient Reimbursement at 85% of Billed Charges LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC outpatient 3.5 GR 52.7 42.16 IMA of Louisiana Commercial PPO 44.8 percent of total billed charges 28.99 44.8 Reimbursement at 85% of billed charges LACRI-LUBE OINT 3.5GM 250 RC 0023024004 NDC outpatient 3.5 GR 52.7 42.16 Aetna Commercial PPO 28.99 percent of total billed charges 28.99 44.8 55 of billed Charges FENTANYL INJ 50MCG/ML 2ML J3010 HCPCS 250 RC 0409909422 NDC inpatient 1 ML 7.83 3.92 BCBS Louisiana PPO 3.92 percent of total billed charges 3.92 6.66 50% of Eligible Charges FENTANYL INJ 50MCG/ML 2ML J3010 HCPCS 250 RC 0409909422 NDC outpatient 1 ML 7.83 6.26 BCBS Louisiana PPO 6.26 percent of total billed charges 4.31 6.66 80% of billed charge FENTANYL INJ 50MCG/ML 2ML J3010 HCPCS 250 RC 0409909422 NDC outpatient 1 ML 7.83 6.26 Cigna Commercial PPO 4.31 percent of total billed charges 4.31 6.66 55% of Billed Charges FENTANYL INJ 50MCG/ML 2ML J3010 HCPCS 250 RC 0409909422 NDC inpatient 1 ML 7.83 3.92 IMA of Louisiana Commercial PPO 6.66 percent of total billed charges 3.92 6.66 Inpatient Reimbursement at 85% of Billed Charges FENTANYL INJ 50MCG/ML 2ML J3010 HCPCS 250 RC 0409909422 NDC outpatient 1 ML 7.83 6.26 IMA of Louisiana Commercial PPO 6.66 percent of total billed charges 4.31 6.66 Reimbursement at 85% of billed charges CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC inpatient 500 ME 1.39 0.7 BCBS Louisiana PPO 0.7 percent of total billed charges 0.7 1.18 50% of Eligible Charges CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC outpatient 500 ME 1.39 1.11 BCBS Louisiana PPO 1.11 percent of total billed charges 0.76 1.18 80% of billed charge CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC outpatient 500 ME 1.39 1.11 Cigna Commercial PPO 0.76 percent of total billed charges 0.76 1.18 55% of Billed Charges CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC inpatient 500 ME 1.39 0.7 IMA of Louisiana Commercial PPO 1.18 percent of total billed charges 0.7 1.18 Inpatient Reimbursement at 85% of Billed Charges CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC outpatient 500 ME 1.39 1.11 IMA of Louisiana Commercial PPO 1.18 percent of total billed charges 0.76 1.18 Reimbursement at 85% of billed charges CEPHALEXIN 500MG CAPSULE 250 RC 6068716301 NDC outpatient 500 ME 1.39 1.11 Aetna Commercial PPO 0.76 percent of total billed charges 0.76 1.18 55 of billed Charges MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC inpatient 30 ML 5.88 2.94 BCBS Louisiana PPO 2.94 percent of total billed charges 2.94 5 50% of Eligible Charges MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC outpatient 30 ML 5.88 4.7 BCBS Louisiana PPO 4.7 percent of total billed charges 3.23 5 80% of billed charge MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC outpatient 30 ML 5.88 4.7 Cigna Commercial PPO 3.23 percent of total billed charges 3.23 5 55% of Billed Charges MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC inpatient 30 ML 5.88 2.94 IMA of Louisiana Commercial PPO 5 percent of total billed charges 2.94 5 Inpatient Reimbursement at 85% of Billed Charges MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC outpatient 30 ML 5.88 4.7 IMA of Louisiana Commercial PPO 5 percent of total billed charges 3.23 5 Reimbursement at 85% of billed charges MILK OF MAGNESIA 30ML 250 RC 6068742976 NDC outpatient 30 ML 5.88 4.7 Aetna Commercial PPO 3.23 percent of total billed charges 3.23 5 55 of billed Charges NEOSTIGMINE 1:1000 1MG/ML 10ML J2710 HCPCS 250 RC 0641614910 NDC inpatient 10 ML 12 6 BCBS Louisiana PPO 6 percent of total billed charges 6 10.2 50% of Eligible Charges NEOSTIGMINE 1:1000 1MG/ML 10ML J2710 HCPCS 250 RC 0641614910 NDC outpatient 10 ML 12 9.6 BCBS Louisiana PPO 9.6 percent of total billed charges 6.6 10.2 80% of billed charge NEOSTIGMINE 1:1000 1MG/ML 10ML J2710 HCPCS 250 RC 0641614910 NDC outpatient 10 ML 12 9.6 Cigna Commercial PPO 6.6 percent of total billed charges 6.6 10.2 55% of Billed Charges NEOSTIGMINE 1:1000 1MG/ML 10ML J2710 HCPCS 250 RC 0641614910 NDC inpatient 10 ML 12 6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6 10.2 Inpatient Reimbursement at 85% of Billed Charges NEOSTIGMINE 1:1000 1MG/ML 10ML J2710 HCPCS 250 RC 0641614910 NDC outpatient 10 ML 12 9.6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6.6 10.2 Reimbursement at 85% of billed charges VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC inpatient 80 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC outpatient 80 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC outpatient 80 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC inpatient 80 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC outpatient 80 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges VERAPAMIL 80MG TABLET 250 RC 2315502601 NDC outpatient 80 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC inpatient 5 ML 22.38 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 11.19 19.02 50% of Eligible Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 BCBS Louisiana PPO 17.9 percent of total billed charges 12.31 19.02 80% of billed charge LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 Cigna Commercial PPO 12.31 percent of total billed charges 12.31 19.02 55% of Billed Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC inpatient 5 ML 22.38 11.19 IMA of Louisiana Commercial PPO 19.02 percent of total billed charges 11.19 19.02 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 2% JELLY 5ML TUBE J2001 HCPCS 250 RC 2502167376 NDC outpatient 5 ML 22.38 17.9 IMA of Louisiana Commercial PPO 19.02 percent of total billed charges 12.31 19.02 Reimbursement at 85% of billed charges LIDOCAINE 2% 5ML SDV J2001 HCPCS 250 RC 6332349526 NDC inpatient 5 ML 5.47 2.74 BCBS Louisiana PPO 2.74 percent of total billed charges 2.74 4.65 50% of Eligible Charges LIDOCAINE 2% 5ML SDV J2001 HCPCS 250 RC 6332349526 NDC outpatient 5 ML 5.47 4.38 BCBS Louisiana PPO 4.38 percent of total billed charges 3.01 4.65 80% of billed charge LIDOCAINE 2% 5ML SDV J2001 HCPCS 250 RC 6332349526 NDC outpatient 5 ML 5.47 4.38 Cigna Commercial PPO 3.01 percent of total billed charges 3.01 4.65 55% of Billed Charges LIDOCAINE 2% 5ML SDV J2001 HCPCS 250 RC 6332349526 NDC inpatient 5 ML 5.47 2.74 IMA of Louisiana Commercial PPO 4.65 percent of total billed charges 2.74 4.65 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 2% 5ML SDV J2001 HCPCS 250 RC 6332349526 NDC outpatient 5 ML 5.47 4.38 IMA of Louisiana Commercial PPO 4.65 percent of total billed charges 3.01 4.65 Reimbursement at 85% of billed charges HYDROMORPHONE 0.2MG/ML PCA 50ML SYRINGE J1170 HCPCS 261 RC 0409263405 NDC inpatient 0.2 ME 561.42 280.71 BCBS Louisiana PPO 280.71 percent of total billed charges 280.71 477.21 50% of Eligible Charges HYDROMORPHONE 0.2MG/ML PCA 50ML SYRINGE J1170 HCPCS 261 RC 0409263405 NDC outpatient 0.2 ME 561.42 449.14 BCBS Louisiana PPO 449.14 percent of total billed charges 308.78 477.21 80% of billed charge HYDROMORPHONE 0.2MG/ML PCA 50ML SYRINGE J1170 HCPCS 261 RC 0409263405 NDC outpatient 0.2 ME 561.42 449.14 Cigna Commercial PPO 308.78 percent of total billed charges 308.78 477.21 55% of Billed Charges HYDROMORPHONE 0.2MG/ML PCA 50ML SYRINGE J1170 HCPCS 261 RC 0409263405 NDC inpatient 0.2 ME 561.42 280.71 IMA of Louisiana Commercial PPO 477.21 percent of total billed charges 280.71 477.21 Inpatient Reimbursement at 85% of Billed Charges HYDROMORPHONE 0.2MG/ML PCA 50ML SYRINGE J1170 HCPCS 261 RC 0409263405 NDC outpatient 0.2 ME 561.42 449.14 IMA of Louisiana Commercial PPO 477.21 percent of total billed charges 308.78 477.21 Reimbursement at 85% of billed charges DILTIAZEM 5MG/ML 10ML INJ J3490 HCPCS 260 RC 0641601410 NDC inpatient 5 ME 33.66 16.83 BCBS Louisiana PPO 16.83 percent of total billed charges 16.83 28.61 50% of Eligible Charges DILTIAZEM 5MG/ML 10ML INJ J3490 HCPCS 260 RC 0641601410 NDC outpatient 5 ME 33.66 26.93 BCBS Louisiana PPO 26.93 percent of total billed charges 18.51 28.61 80% of billed charge DILTIAZEM 5MG/ML 10ML INJ J3490 HCPCS 260 RC 0641601410 NDC outpatient 5 ME 33.66 26.93 Cigna Commercial PPO 18.51 percent of total billed charges 18.51 28.61 55% of Billed Charges DILTIAZEM 5MG/ML 10ML INJ J3490 HCPCS 260 RC 0641601410 NDC inpatient 5 ME 33.66 16.83 IMA of Louisiana Commercial PPO 28.61 percent of total billed charges 16.83 28.61 Inpatient Reimbursement at 85% of Billed Charges DILTIAZEM 5MG/ML 10ML INJ J3490 HCPCS 260 RC 0641601410 NDC outpatient 5 ME 33.66 26.93 IMA of Louisiana Commercial PPO 28.61 percent of total billed charges 18.51 28.61 Reimbursement at 85% of billed charges ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC inpatient 10 ME 8.88 4.44 BCBS Louisiana PPO 4.44 percent of total billed charges 4.44 7.55 50% of Eligible Charges ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC outpatient 10 ME 8.88 7.1 BCBS Louisiana PPO 7.1 percent of total billed charges 4.88 7.55 80% of billed charge ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC outpatient 10 ME 8.88 7.1 Cigna Commercial PPO 4.88 percent of total billed charges 4.88 7.55 55% of Billed Charges ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC inpatient 10 ME 8.88 4.44 IMA of Louisiana Commercial PPO 7.55 percent of total billed charges 4.44 7.55 Inpatient Reimbursement at 85% of Billed Charges ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC outpatient 10 ME 8.88 7.1 IMA of Louisiana Commercial PPO 7.55 percent of total billed charges 4.88 7.55 Reimbursement at 85% of billed charges ROCURONIUM 10MG/ML 5ML 250 RC 6332342605 NDC outpatient 10 ME 8.88 7.1 Aetna Commercial PPO 4.88 percent of total billed charges 4.88 7.55 55 of billed Charges POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC inpatient 20 UN 1.49 0.75 BCBS Louisiana PPO 0.75 percent of total billed charges 0.75 1.27 50% of Eligible Charges POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC outpatient 20 UN 1.49 1.19 BCBS Louisiana PPO 1.19 percent of total billed charges 0.82 1.27 80% of billed charge POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC outpatient 20 UN 1.49 1.19 Cigna Commercial PPO 0.82 percent of total billed charges 0.82 1.27 55% of Billed Charges POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC inpatient 20 UN 1.49 0.75 IMA of Louisiana Commercial PPO 1.27 percent of total billed charges 0.75 1.27 Inpatient Reimbursement at 85% of Billed Charges POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC outpatient 20 UN 1.49 1.19 IMA of Louisiana Commercial PPO 1.27 percent of total billed charges 0.82 1.27 Reimbursement at 85% of billed charges POTASSIUM CHLORIDE 20MEQ TABLET 250 RC 0245531989 NDC outpatient 20 UN 1.49 1.19 Aetna Commercial PPO 0.82 percent of total billed charges 0.82 1.27 55 of billed Charges SODIUM CHL 0.9% 250ML J7050 HCPCS 260 RC 0338004902 NDC inpatient 250 ML 21.86 10.93 BCBS Louisiana PPO 10.93 percent of total billed charges 10.93 18.58 50% of Eligible Charges SODIUM CHL 0.9% 250ML J7050 HCPCS 260 RC 0338004902 NDC outpatient 250 ML 21.86 17.49 BCBS Louisiana PPO 17.49 percent of total billed charges 12.02 18.58 80% of billed charge SODIUM CHL 0.9% 250ML J7050 HCPCS 260 RC 0338004902 NDC outpatient 250 ML 21.86 17.49 Cigna Commercial PPO 12.02 percent of total billed charges 12.02 18.58 55% of Billed Charges SODIUM CHL 0.9% 250ML J7050 HCPCS 260 RC 0338004902 NDC inpatient 250 ML 21.86 10.93 IMA of Louisiana Commercial PPO 18.58 percent of total billed charges 10.93 18.58 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 250ML J7050 HCPCS 260 RC 0338004902 NDC outpatient 250 ML 21.86 17.49 IMA of Louisiana Commercial PPO 18.58 percent of total billed charges 12.02 18.58 Reimbursement at 85% of billed charges GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GLIPIZIDE 5MG TAB 250 RC 0591046001 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC inpatient 1 EA 26.2 13.1 BCBS Louisiana PPO 13.1 percent of total billed charges 13.1 22.27 50% of Eligible Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 BCBS Louisiana PPO 20.96 percent of total billed charges 14.41 22.27 80% of billed charge PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 Cigna Commercial PPO 14.41 percent of total billed charges 14.41 22.27 55% of Billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC inpatient 1 EA 26.2 13.1 IMA of Louisiana Commercial PPO 22.27 percent of total billed charges 13.1 22.27 Inpatient Reimbursement at 85% of Billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 IMA of Louisiana Commercial PPO 22.27 percent of total billed charges 14.41 22.27 Reimbursement at 85% of billed charges NALBUPHINE 10MG/ML 1ML J2300 HCPCS 250 RC 0409146371 NDC inpatient 10 ME 18.9 9.45 BCBS Louisiana PPO 9.45 percent of total billed charges 9.45 16.07 50% of Eligible Charges NALBUPHINE 10MG/ML 1ML J2300 HCPCS 250 RC 0409146371 NDC outpatient 10 ME 18.9 15.12 BCBS Louisiana PPO 15.12 percent of total billed charges 10.4 16.07 80% of billed charge NALBUPHINE 10MG/ML 1ML J2300 HCPCS 250 RC 0409146371 NDC outpatient 10 ME 18.9 15.12 Cigna Commercial PPO 10.4 percent of total billed charges 10.4 16.07 55% of Billed Charges NALBUPHINE 10MG/ML 1ML J2300 HCPCS 250 RC 0409146371 NDC inpatient 10 ME 18.9 9.45 IMA of Louisiana Commercial PPO 16.07 percent of total billed charges 9.45 16.07 Inpatient Reimbursement at 85% of Billed Charges NALBUPHINE 10MG/ML 1ML J2300 HCPCS 250 RC 0409146371 NDC outpatient 10 ME 18.9 15.12 IMA of Louisiana Commercial PPO 16.07 percent of total billed charges 10.4 16.07 Reimbursement at 85% of billed charges TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC inpatient 0.4 ME 1.53 0.77 BCBS Louisiana PPO 0.77 percent of total billed charges 0.77 1.3 50% of Eligible Charges TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC outpatient 0.4 ME 1.53 1.22 BCBS Louisiana PPO 1.22 percent of total billed charges 0.84 1.3 80% of billed charge TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC outpatient 0.4 ME 1.53 1.22 Cigna Commercial PPO 0.84 percent of total billed charges 0.84 1.3 55% of Billed Charges TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC inpatient 0.4 ME 1.53 0.77 IMA of Louisiana Commercial PPO 1.3 percent of total billed charges 0.77 1.3 Inpatient Reimbursement at 85% of Billed Charges TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC outpatient 0.4 ME 1.53 1.22 IMA of Louisiana Commercial PPO 1.3 percent of total billed charges 0.84 1.3 Reimbursement at 85% of billed charges TAMSULOSINE 0.4MG CAPSULE 250 RC 0904738361 NDC outpatient 0.4 ME 1.53 1.22 Aetna Commercial PPO 0.84 percent of total billed charges 0.84 1.3 55 of billed Charges MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC inpatient 10 ME 1.38 0.69 BCBS Louisiana PPO 0.69 percent of total billed charges 0.69 1.17 50% of Eligible Charges MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC outpatient 10 ME 1.38 1.1 BCBS Louisiana PPO 1.1 percent of total billed charges 0.76 1.17 80% of billed charge MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC outpatient 10 ME 1.38 1.1 Cigna Commercial PPO 0.76 percent of total billed charges 0.76 1.17 55% of Billed Charges MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC inpatient 10 ME 1.38 0.69 IMA of Louisiana Commercial PPO 1.17 percent of total billed charges 0.69 1.17 Inpatient Reimbursement at 85% of Billed Charges MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC outpatient 10 ME 1.38 1.1 IMA of Louisiana Commercial PPO 1.17 percent of total billed charges 0.76 1.17 Reimbursement at 85% of billed charges MONTELUKAST 10MG TABLET 250 RC 0904680861 NDC outpatient 10 ME 1.38 1.1 Aetna Commercial PPO 0.76 percent of total billed charges 0.76 1.17 55 of billed Charges TRAZODONE 50MG TABLET 250 RC 0904686861 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TRAZODONE 50MG TABLET 250 RC 0904686861 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TRAZODONE 50MG TABLET 250 RC 0904686861 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TRAZODONE 50MG TABLET 250 RC 0904686861 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TRAZODONE 50MG TABLET 250 RC 0904686861 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TRAZODONE 50MG TABLET 250 RC 0904686861 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TRIAMTEREN/HCTZ 37.5/25MG CAPSULES 250 RC 0781207401 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DIAZEPAM 5MG TABLET 250 RC 0172392660 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC inpatient 100 ML 14.43 7.22 BCBS Louisiana PPO 7.22 percent of total billed charges 7.22 12.27 50% of Eligible Charges SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC outpatient 100 ML 14.43 11.54 BCBS Louisiana PPO 11.54 percent of total billed charges 7.94 12.27 80% of billed charge SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC outpatient 100 ML 14.43 11.54 Cigna Commercial PPO 7.94 percent of total billed charges 7.94 12.27 55% of Billed Charges SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC inpatient 100 ML 14.43 7.22 IMA of Louisiana Commercial PPO 12.27 percent of total billed charges 7.22 12.27 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC outpatient 100 ML 14.43 11.54 IMA of Louisiana Commercial PPO 12.27 percent of total billed charges 7.94 12.27 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 100 ML 260 RC 0338004938 NDC outpatient 100 ML 14.43 11.54 Aetna Commercial PPO 7.94 percent of total billed charges 7.94 12.27 55 of billed Charges PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC inpatient 40 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC outpatient 40 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC outpatient 40 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC inpatient 40 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC outpatient 40 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PROPRANOLOL 40MG TAB 250 RC 6923820791 NDC outpatient 40 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC inpatient 2 ME 2.52 1.26 BCBS Louisiana PPO 1.26 percent of total billed charges 1.26 2.14 50% of Eligible Charges TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC outpatient 2 ME 2.52 2.02 BCBS Louisiana PPO 2.02 percent of total billed charges 1.39 2.14 80% of billed charge TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC outpatient 2 ME 2.52 2.02 Cigna Commercial PPO 1.39 percent of total billed charges 1.39 2.14 55% of Billed Charges TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC inpatient 2 ME 2.52 1.26 IMA of Louisiana Commercial PPO 2.14 percent of total billed charges 1.26 2.14 Inpatient Reimbursement at 85% of Billed Charges TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC outpatient 2 ME 2.52 2.02 IMA of Louisiana Commercial PPO 2.14 percent of total billed charges 1.39 2.14 Reimbursement at 85% of billed charges TOLTERODINE TART ER 2MG CAPSULE 250 RC 3172260730 NDC outpatient 2 ME 2.52 2.02 Aetna Commercial PPO 1.39 percent of total billed charges 1.39 2.14 55 of billed Charges OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC inpatient 10 ME 36.35 18.18 BCBS Louisiana PPO 18.18 percent of total billed charges 18.18 30.9 50% of Eligible Charges OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC outpatient 10 ME 36.35 29.08 BCBS Louisiana PPO 29.08 percent of total billed charges 19.99 30.9 80% of billed charge OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC outpatient 10 ME 36.35 29.08 Cigna Commercial PPO 19.99 percent of total billed charges 19.99 30.9 55% of Billed Charges OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC inpatient 10 ME 36.35 18.18 IMA of Louisiana Commercial PPO 30.9 percent of total billed charges 18.18 30.9 Inpatient Reimbursement at 85% of Billed Charges OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC outpatient 10 ME 36.35 29.08 IMA of Louisiana Commercial PPO 30.9 percent of total billed charges 19.99 30.9 Reimbursement at 85% of billed charges OXYCONTIN CR 10MG TABLET 250 RC 5901141020 NDC outpatient 10 ME 36.35 29.08 Aetna Commercial PPO 19.99 percent of total billed charges 19.99 30.9 55 of billed Charges DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC inpatient 500 ME 13.94 6.97 BCBS Louisiana PPO 6.97 percent of total billed charges 6.97 11.85 50% of Eligible Charges DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC outpatient 500 ME 13.94 11.15 BCBS Louisiana PPO 11.15 percent of total billed charges 7.67 11.85 80% of billed charge DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC outpatient 500 ME 13.94 11.15 Cigna Commercial PPO 7.67 percent of total billed charges 7.67 11.85 55% of Billed Charges DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC inpatient 500 ME 13.94 6.97 IMA of Louisiana Commercial PPO 11.85 percent of total billed charges 6.97 11.85 Inpatient Reimbursement at 85% of Billed Charges DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC outpatient 500 ME 13.94 11.15 IMA of Louisiana Commercial PPO 11.85 percent of total billed charges 7.67 11.85 Reimbursement at 85% of billed charges DEPAKOTE ER 500MG TAB NON-FORMULARY 250 RC 5111053401 NDC outpatient 500 ME 13.94 11.15 Aetna Commercial PPO 7.67 percent of total billed charges 7.67 11.85 55 of billed Charges POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC inpatient 0.05 F2 1.85 0.93 BCBS Louisiana PPO 0.93 percent of total billed charges 0.93 1.57 50% of Eligible Charges POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC outpatient 0.05 F2 1.85 1.48 BCBS Louisiana PPO 1.48 percent of total billed charges 1.02 1.57 80% of billed charge POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC outpatient 0.05 F2 1.85 1.48 Cigna Commercial PPO 1.02 percent of total billed charges 1.02 1.57 55% of Billed Charges POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC inpatient 0.05 F2 1.85 0.93 IMA of Louisiana Commercial PPO 1.57 percent of total billed charges 0.93 1.57 Inpatient Reimbursement at 85% of Billed Charges POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC outpatient 0.05 F2 1.85 1.48 IMA of Louisiana Commercial PPO 1.57 percent of total billed charges 1.02 1.57 Reimbursement at 85% of billed charges POVIDONE IODINE OINT 0.05OZ 250 RC 5238001262 NDC outpatient 0.05 F2 1.85 1.48 Aetna Commercial PPO 1.02 percent of total billed charges 1.02 1.57 55 of billed Charges METFORMIN 500MG TABLET 250 RC 2315584101 NDC inpatient 500 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METFORMIN 500MG TABLET 250 RC 2315584101 NDC outpatient 500 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METFORMIN 500MG TABLET 250 RC 2315584101 NDC outpatient 500 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METFORMIN 500MG TABLET 250 RC 2315584101 NDC inpatient 500 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METFORMIN 500MG TABLET 250 RC 2315584101 NDC outpatient 500 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METFORMIN 500MG TABLET 250 RC 2315584101 NDC outpatient 500 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CRESTOR 10MG TABLET 250 RC 6068724501 NDC inpatient 10 ME 5.29 2.65 BCBS Louisiana PPO 2.65 percent of total billed charges 2.65 4.5 50% of Eligible Charges CRESTOR 10MG TABLET 250 RC 6068724501 NDC outpatient 10 ME 5.29 4.23 BCBS Louisiana PPO 4.23 percent of total billed charges 2.91 4.5 80% of billed charge CRESTOR 10MG TABLET 250 RC 6068724501 NDC outpatient 10 ME 5.29 4.23 Cigna Commercial PPO 2.91 percent of total billed charges 2.91 4.5 55% of Billed Charges CRESTOR 10MG TABLET 250 RC 6068724501 NDC inpatient 10 ME 5.29 2.65 IMA of Louisiana Commercial PPO 4.5 percent of total billed charges 2.65 4.5 Inpatient Reimbursement at 85% of Billed Charges CRESTOR 10MG TABLET 250 RC 6068724501 NDC outpatient 10 ME 5.29 4.23 IMA of Louisiana Commercial PPO 4.5 percent of total billed charges 2.91 4.5 Reimbursement at 85% of billed charges CRESTOR 10MG TABLET 250 RC 6068724501 NDC outpatient 10 ME 5.29 4.23 Aetna Commercial PPO 2.91 percent of total billed charges 2.91 4.5 55 of billed Charges GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC inpatient 2 ME 1.61 0.81 BCBS Louisiana PPO 0.81 percent of total billed charges 0.81 1.37 50% of Eligible Charges GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC outpatient 2 ME 1.61 1.29 BCBS Louisiana PPO 1.29 percent of total billed charges 0.89 1.37 80% of billed charge GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC outpatient 2 ME 1.61 1.29 Cigna Commercial PPO 0.89 percent of total billed charges 0.89 1.37 55% of Billed Charges GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC inpatient 2 ME 1.61 0.81 IMA of Louisiana Commercial PPO 1.37 percent of total billed charges 0.81 1.37 Inpatient Reimbursement at 85% of Billed Charges GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC outpatient 2 ME 1.61 1.29 IMA of Louisiana Commercial PPO 1.37 percent of total billed charges 0.89 1.37 Reimbursement at 85% of billed charges GLIMEPIRIDE 2MG TABLET 250 RC 5026835911 NDC outpatient 2 ME 1.61 1.29 Aetna Commercial PPO 0.89 percent of total billed charges 0.89 1.37 55 of billed Charges SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SPIRONOLACTONE 25MG TABLET 250 RC 6068746511 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC inpatient 75 ME 1.14 0.57 BCBS Louisiana PPO 0.57 percent of total billed charges 0.57 0.97 50% of Eligible Charges CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC outpatient 75 ME 1.14 0.91 BCBS Louisiana PPO 0.91 percent of total billed charges 0.63 0.97 80% of billed charge CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC outpatient 75 ME 1.14 0.91 Cigna Commercial PPO 0.63 percent of total billed charges 0.63 0.97 55% of Billed Charges CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC inpatient 75 ME 1.14 0.57 IMA of Louisiana Commercial PPO 0.97 percent of total billed charges 0.57 0.97 Inpatient Reimbursement at 85% of Billed Charges CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC outpatient 75 ME 1.14 0.91 IMA of Louisiana Commercial PPO 0.97 percent of total billed charges 0.63 0.97 Reimbursement at 85% of billed charges CLOPIDOGREL 75MG TABLET 250 RC 5107955720 NDC outpatient 75 ME 1.14 0.91 Aetna Commercial PPO 0.63 percent of total billed charges 0.63 0.97 55 of billed Charges TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC inpatient 25 ME 1.12 0.56 BCBS Louisiana PPO 0.56 percent of total billed charges 0.56 0.95 50% of Eligible Charges TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC outpatient 25 ME 1.12 0.9 BCBS Louisiana PPO 0.9 percent of total billed charges 0.62 0.95 80% of billed charge TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC outpatient 25 ME 1.12 0.9 Cigna Commercial PPO 0.62 percent of total billed charges 0.62 0.95 55% of Billed Charges TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC inpatient 25 ME 1.12 0.56 IMA of Louisiana Commercial PPO 0.95 percent of total billed charges 0.56 0.95 Inpatient Reimbursement at 85% of Billed Charges TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC outpatient 25 ME 1.12 0.9 IMA of Louisiana Commercial PPO 0.95 percent of total billed charges 0.62 0.95 Reimbursement at 85% of billed charges TOPIRAMATE 25MG TABLET 250 RC 0904692861 NDC outpatient 25 ME 1.12 0.9 Aetna Commercial PPO 0.62 percent of total billed charges 0.62 0.95 55 of billed Charges LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC inpatient 0.088 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC outpatient 0.088 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC outpatient 0.088 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC inpatient 0.088 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC outpatient 0.088 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LEVOTHYROXINE 88MCG TABLET 250 RC 1672945015 NDC outpatient 0.088 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FINASTERIDE 5MG TABLET 250 RC 3172252590 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC inpatient 30 ME 1.37 0.69 BCBS Louisiana PPO 0.69 percent of total billed charges 0.69 1.16 50% of Eligible Charges ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC outpatient 30 ME 1.37 1.1 BCBS Louisiana PPO 1.1 percent of total billed charges 0.75 1.16 80% of billed charge ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC outpatient 30 ME 1.37 1.1 Cigna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55% of Billed Charges ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC inpatient 30 ME 1.37 0.69 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.69 1.16 Inpatient Reimbursement at 85% of Billed Charges ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC outpatient 30 ME 1.37 1.1 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.75 1.16 Reimbursement at 85% of billed charges ISOSORBIDE MONO ER 30MG TAB NON-FORM 250 RC 6068778301 NDC outpatient 30 ME 1.37 1.1 Aetna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55 of billed Charges CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CARVEDILOL 25MG TABLET 250 RC 0904630361 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC inpatient 1 EA 9.22 4.61 BCBS Louisiana PPO 4.61 percent of total billed charges 4.61 7.84 50% of Eligible Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 BCBS Louisiana PPO 7.38 percent of total billed charges 5.07 7.84 80% of billed charge LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 Cigna Commercial PPO 5.07 percent of total billed charges 5.07 7.84 55% of Billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC inpatient 1 EA 9.22 4.61 IMA of Louisiana Commercial PPO 7.84 percent of total billed charges 4.61 7.84 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 IMA of Louisiana Commercial PPO 7.84 percent of total billed charges 5.07 7.84 Reimbursement at 85% of billed charges ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ISOSORBIDE MONO 10MG TABLET 250 RC 0228263111 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC inpatient 6 F2 14.16 7.08 BCBS Louisiana PPO 7.08 percent of total billed charges 7.08 12.04 50% of Eligible Charges CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC outpatient 6 F2 14.16 11.33 BCBS Louisiana PPO 11.33 percent of total billed charges 7.79 12.04 80% of billed charge CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC outpatient 6 F2 14.16 11.33 Cigna Commercial PPO 7.79 percent of total billed charges 7.79 12.04 55% of Billed Charges CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC inpatient 6 F2 14.16 7.08 IMA of Louisiana Commercial PPO 12.04 percent of total billed charges 7.08 12.04 Inpatient Reimbursement at 85% of Billed Charges CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC outpatient 6 F2 14.16 11.33 IMA of Louisiana Commercial PPO 12.04 percent of total billed charges 7.79 12.04 Reimbursement at 85% of billed charges CHLORASEPTIC SPRAY 6OZ. 250 RC 0536122858 NDC outpatient 6 F2 14.16 11.33 Aetna Commercial PPO 7.79 percent of total billed charges 7.79 12.04 55 of billed Charges AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC inpatient 30 ML 37.14 18.57 BCBS Louisiana PPO 18.57 percent of total billed charges 18.57 31.57 50% of Eligible Charges AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC outpatient 30 ML 37.14 29.71 BCBS Louisiana PPO 29.71 percent of total billed charges 20.43 31.57 80% of billed charge AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC outpatient 30 ML 37.14 29.71 Cigna Commercial PPO 20.43 percent of total billed charges 20.43 31.57 55% of Billed Charges AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC inpatient 30 ML 37.14 18.57 IMA of Louisiana Commercial PPO 31.57 percent of total billed charges 18.57 31.57 Inpatient Reimbursement at 85% of Billed Charges AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC outpatient 30 ML 37.14 29.71 IMA of Louisiana Commercial PPO 31.57 percent of total billed charges 20.43 31.57 Reimbursement at 85% of billed charges AZELASTINE 0.15% 205.5MCG 30ML NASAL SPY 250 RC 6050508335 NDC outpatient 30 ML 37.14 29.71 Aetna Commercial PPO 20.43 percent of total billed charges 20.43 31.57 55 of billed Charges LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC inpatient 0.137 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC outpatient 0.137 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC outpatient 0.137 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC inpatient 0.137 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC outpatient 0.137 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LEVOTHYROXINE 137MCG TAB 250 RC 1672945415 NDC outpatient 0.137 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges METHYLPREDNISOLONE 4MG PACK J7509 HCPCS 250 RC 4280640021 NDC inpatient 4 ME 18.48 9.24 BCBS Louisiana PPO 9.24 percent of total billed charges 9.24 15.71 50% of Eligible Charges METHYLPREDNISOLONE 4MG PACK J7509 HCPCS 250 RC 4280640021 NDC outpatient 4 ME 18.48 14.78 BCBS Louisiana PPO 14.78 percent of total billed charges 10.16 15.71 80% of billed charge METHYLPREDNISOLONE 4MG PACK J7509 HCPCS 250 RC 4280640021 NDC outpatient 4 ME 18.48 14.78 Cigna Commercial PPO 10.16 percent of total billed charges 10.16 15.71 55% of Billed Charges METHYLPREDNISOLONE 4MG PACK J7509 HCPCS 250 RC 4280640021 NDC inpatient 4 ME 18.48 9.24 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 9.24 15.71 Inpatient Reimbursement at 85% of Billed Charges METHYLPREDNISOLONE 4MG PACK J7509 HCPCS 250 RC 4280640021 NDC outpatient 4 ME 18.48 14.78 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 10.16 15.71 Reimbursement at 85% of billed charges PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC inpatient 100 ME 2.23 1.12 BCBS Louisiana PPO 1.12 percent of total billed charges 1.12 1.9 50% of Eligible Charges PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC outpatient 100 ME 2.23 1.78 BCBS Louisiana PPO 1.78 percent of total billed charges 1.23 1.9 80% of billed charge PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC outpatient 100 ME 2.23 1.78 Cigna Commercial PPO 1.23 percent of total billed charges 1.23 1.9 55% of Billed Charges PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC inpatient 100 ME 2.23 1.12 IMA of Louisiana Commercial PPO 1.9 percent of total billed charges 1.12 1.9 Inpatient Reimbursement at 85% of Billed Charges PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC outpatient 100 ME 2.23 1.78 IMA of Louisiana Commercial PPO 1.9 percent of total billed charges 1.23 1.9 Reimbursement at 85% of billed charges PREGABALIN 100MG CAPSULE 250 RC 6068750601 NDC outpatient 100 ME 2.23 1.78 Aetna Commercial PPO 1.23 percent of total billed charges 1.23 1.9 55 of billed Charges CIPROFLOXACIN 400MG IVPB 200ML J0744 HCPCS 250 RC 2502111487 NDC inpatient 400 ME 39.75 19.88 BCBS Louisiana PPO 19.88 percent of total billed charges 19.88 33.79 50% of Eligible Charges CIPROFLOXACIN 400MG IVPB 200ML J0744 HCPCS 250 RC 2502111487 NDC outpatient 400 ME 39.75 31.8 BCBS Louisiana PPO 31.8 percent of total billed charges 21.86 33.79 80% of billed charge CIPROFLOXACIN 400MG IVPB 200ML J0744 HCPCS 250 RC 2502111487 NDC outpatient 400 ME 39.75 31.8 Cigna Commercial PPO 21.86 percent of total billed charges 21.86 33.79 55% of Billed Charges CIPROFLOXACIN 400MG IVPB 200ML J0744 HCPCS 250 RC 2502111487 NDC inpatient 400 ME 39.75 19.88 IMA of Louisiana Commercial PPO 33.79 percent of total billed charges 19.88 33.79 Inpatient Reimbursement at 85% of Billed Charges CIPROFLOXACIN 400MG IVPB 200ML J0744 HCPCS 250 RC 2502111487 NDC outpatient 400 ME 39.75 31.8 IMA of Louisiana Commercial PPO 33.79 percent of total billed charges 21.86 33.79 Reimbursement at 85% of billed charges IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC inpatient 200 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC outpatient 200 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC outpatient 200 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC inpatient 200 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC outpatient 200 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges IBUPROFEN 200MG TABLET 250 RC 0904791461 NDC outpatient 200 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC inpatient 1 GR 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC outpatient 1 GR 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC outpatient 1 GR 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC inpatient 1 GR 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC outpatient 1 GR 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LOVAZA 1GM CAPSULE 250 RC 6050531707 NDC outpatient 1 GR 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LORAZEPAM 2MG/ML 1ML INJ. J2060 HCPCS 250 RC 0641620725 NDC inpatient 2 ME 2.94 1.47 BCBS Louisiana PPO 1.47 percent of total billed charges 1.47 2.5 50% of Eligible Charges LORAZEPAM 2MG/ML 1ML INJ. J2060 HCPCS 250 RC 0641620725 NDC outpatient 2 ME 2.94 2.35 BCBS Louisiana PPO 2.35 percent of total billed charges 1.62 2.5 80% of billed charge LORAZEPAM 2MG/ML 1ML INJ. J2060 HCPCS 250 RC 0641620725 NDC outpatient 2 ME 2.94 2.35 Cigna Commercial PPO 1.62 percent of total billed charges 1.62 2.5 55% of Billed Charges LORAZEPAM 2MG/ML 1ML INJ. J2060 HCPCS 250 RC 0641620725 NDC inpatient 2 ME 2.94 1.47 IMA of Louisiana Commercial PPO 2.5 percent of total billed charges 1.47 2.5 Inpatient Reimbursement at 85% of Billed Charges LORAZEPAM 2MG/ML 1ML INJ. J2060 HCPCS 250 RC 0641620725 NDC outpatient 2 ME 2.94 2.35 IMA of Louisiana Commercial PPO 2.5 percent of total billed charges 1.62 2.5 Reimbursement at 85% of billed charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC inpatient 1 EA 445.35 222.68 BCBS Louisiana PPO 222.68 percent of total billed charges 222.68 378.55 50% of Eligible Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 BCBS Louisiana PPO 356.28 percent of total billed charges 244.94 378.55 80% of billed charge PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 Cigna Commercial PPO 244.94 percent of total billed charges 244.94 378.55 55% of Billed Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC inpatient 1 EA 445.35 222.68 IMA of Louisiana Commercial PPO 378.55 percent of total billed charges 222.68 378.55 Inpatient Reimbursement at 85% of Billed Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 IMA of Louisiana Commercial PPO 378.55 percent of total billed charges 244.94 378.55 Reimbursement at 85% of billed charges MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC inpatient 2 ME 30.18 15.09 BCBS Louisiana PPO 15.09 percent of total billed charges 15.09 25.65 50% of Eligible Charges MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC outpatient 2 ME 30.18 24.14 BCBS Louisiana PPO 24.14 percent of total billed charges 16.6 25.65 80% of billed charge MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC outpatient 2 ME 30.18 24.14 Cigna Commercial PPO 16.6 percent of total billed charges 16.6 25.65 55% of Billed Charges MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC inpatient 2 ME 30.18 15.09 IMA of Louisiana Commercial PPO 25.65 percent of total billed charges 15.09 25.65 Inpatient Reimbursement at 85% of Billed Charges MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC outpatient 2 ME 30.18 24.14 IMA of Louisiana Commercial PPO 25.65 percent of total billed charges 16.6 25.65 Reimbursement at 85% of billed charges MIDAZOLAM 2MG/ML 5ML SYRUP 250 RC 6068757686 NDC outpatient 2 ME 30.18 24.14 Aetna Commercial PPO 16.6 percent of total billed charges 16.6 25.65 55 of billed Charges CLINDAMYCIN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 5886460740 NDC inpatient 150 ME 4.92 2.46 BCBS Louisiana PPO 2.46 percent of total billed charges 2.46 4.18 50% of Eligible Charges CLINDAMYCIN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 5886460740 NDC outpatient 150 ME 4.92 3.94 BCBS Louisiana PPO 3.94 percent of total billed charges 2.71 4.18 80% of billed charge CLINDAMYCIN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 5886460740 NDC outpatient 150 ME 4.92 3.94 Cigna Commercial PPO 2.71 percent of total billed charges 2.71 4.18 55% of Billed Charges CLINDAMYCIN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 5886460740 NDC inpatient 150 ME 4.92 2.46 IMA of Louisiana Commercial PPO 4.18 percent of total billed charges 2.46 4.18 Inpatient Reimbursement at 85% of Billed Charges CLINDAMYCIN 150MG CAP NON-FORMULARY J8499 HCPCS 250 RC 5886460740 NDC outpatient 150 ME 4.92 3.94 IMA of Louisiana Commercial PPO 4.18 percent of total billed charges 2.71 4.18 Reimbursement at 85% of billed charges LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC inpatient 1.25 ME 3.2 1.6 BCBS Louisiana PPO 1.6 percent of total billed charges 1.6 2.72 50% of Eligible Charges LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC outpatient 1.25 ME 3.2 2.56 BCBS Louisiana PPO 2.56 percent of total billed charges 1.76 2.72 80% of billed charge LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC outpatient 1.25 ME 3.2 2.56 Cigna Commercial PPO 1.76 percent of total billed charges 1.76 2.72 55% of Billed Charges LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC inpatient 1.25 ME 3.2 1.6 IMA of Louisiana Commercial PPO 2.72 percent of total billed charges 1.6 2.72 Inpatient Reimbursement at 85% of Billed Charges LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC outpatient 1.25 ME 3.2 2.56 IMA of Louisiana Commercial PPO 2.72 percent of total billed charges 1.76 2.72 Reimbursement at 85% of billed charges LEVALBUTEROL 1.25/3ML UD INHALANT 250 RC 3557344525 NDC outpatient 1.25 ME 3.2 2.56 Aetna Commercial PPO 1.76 percent of total billed charges 1.76 2.72 55 of billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC inpatient 1 EA 1.81 0.91 BCBS Louisiana PPO 0.91 percent of total billed charges 0.91 1.54 50% of Eligible Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 BCBS Louisiana PPO 1.45 percent of total billed charges 1 1.54 80% of billed charge LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 Cigna Commercial PPO 1 percent of total billed charges 1 1.54 55% of Billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC inpatient 1 EA 1.81 0.91 IMA of Louisiana Commercial PPO 1.54 percent of total billed charges 0.91 1.54 Inpatient Reimbursement at 85% of Billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 IMA of Louisiana Commercial PPO 1.54 percent of total billed charges 1 1.54 Reimbursement at 85% of billed charges LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC inpatient 2 ME 1.78 0.89 BCBS Louisiana PPO 0.89 percent of total billed charges 0.89 1.51 50% of Eligible Charges LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC outpatient 2 ME 1.78 1.42 BCBS Louisiana PPO 1.42 percent of total billed charges 0.98 1.51 80% of billed charge LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC outpatient 2 ME 1.78 1.42 Cigna Commercial PPO 0.98 percent of total billed charges 0.98 1.51 55% of Billed Charges LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC inpatient 2 ME 1.78 0.89 IMA of Louisiana Commercial PPO 1.51 percent of total billed charges 0.89 1.51 Inpatient Reimbursement at 85% of Billed Charges LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC outpatient 2 ME 1.78 1.42 IMA of Louisiana Commercial PPO 1.51 percent of total billed charges 0.98 1.51 Reimbursement at 85% of billed charges LOPERAMIDE 2MG CAPSULE 250 RC 6945227120 NDC outpatient 2 ME 1.78 1.42 Aetna Commercial PPO 0.98 percent of total billed charges 0.98 1.51 55 of billed Charges DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC inpatient 10 ME 2.1 1.05 BCBS Louisiana PPO 1.05 percent of total billed charges 1.05 1.79 50% of Eligible Charges DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC outpatient 10 ME 2.1 1.68 BCBS Louisiana PPO 1.68 percent of total billed charges 1.16 1.79 80% of billed charge DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC outpatient 10 ME 2.1 1.68 Cigna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55% of Billed Charges DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC inpatient 10 ME 2.1 1.05 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.05 1.79 Inpatient Reimbursement at 85% of Billed Charges DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC outpatient 10 ME 2.1 1.68 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.16 1.79 Reimbursement at 85% of billed charges DICYCLOMINE 10MG CAPSULE 250 RC 6068736901 NDC outpatient 10 ME 2.1 1.68 Aetna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55 of billed Charges BUPIVACAINE 0.5% W/EPI 50ML J3490 HCPCS 250 RC 0409175550 NDC inpatient 50 ML 57.08 28.54 BCBS Louisiana PPO 28.54 percent of total billed charges 28.54 48.52 50% of Eligible Charges BUPIVACAINE 0.5% W/EPI 50ML J3490 HCPCS 250 RC 0409175550 NDC outpatient 50 ML 57.08 45.66 BCBS Louisiana PPO 45.66 percent of total billed charges 31.39 48.52 80% of billed charge BUPIVACAINE 0.5% W/EPI 50ML J3490 HCPCS 250 RC 0409175550 NDC outpatient 50 ML 57.08 45.66 Cigna Commercial PPO 31.39 percent of total billed charges 31.39 48.52 55% of Billed Charges BUPIVACAINE 0.5% W/EPI 50ML J3490 HCPCS 250 RC 0409175550 NDC inpatient 50 ML 57.08 28.54 IMA of Louisiana Commercial PPO 48.52 percent of total billed charges 28.54 48.52 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.5% W/EPI 50ML J3490 HCPCS 250 RC 0409175550 NDC outpatient 50 ML 57.08 45.66 IMA of Louisiana Commercial PPO 48.52 percent of total billed charges 31.39 48.52 Reimbursement at 85% of billed charges DEPAKOTE 125MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0074732513 NDC inpatient 125 ME 2.29 1.15 BCBS Louisiana PPO 1.15 percent of total billed charges 1.15 1.95 50% of Eligible Charges DEPAKOTE 125MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0074732513 NDC outpatient 125 ME 2.29 1.83 BCBS Louisiana PPO 1.83 percent of total billed charges 1.26 1.95 80% of billed charge DEPAKOTE 125MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0074732513 NDC outpatient 125 ME 2.29 1.83 Cigna Commercial PPO 1.26 percent of total billed charges 1.26 1.95 55% of Billed Charges DEPAKOTE 125MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0074732513 NDC inpatient 125 ME 2.29 1.15 IMA of Louisiana Commercial PPO 1.95 percent of total billed charges 1.15 1.95 Inpatient Reimbursement at 85% of Billed Charges DEPAKOTE 125MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0074732513 NDC outpatient 125 ME 2.29 1.83 IMA of Louisiana Commercial PPO 1.95 percent of total billed charges 1.26 1.95 Reimbursement at 85% of billed charges TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC inpatient 100 ME 9.45 4.73 BCBS Louisiana PPO 4.73 percent of total billed charges 4.73 8.03 50% of Eligible Charges TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC outpatient 100 ME 9.45 7.56 BCBS Louisiana PPO 7.56 percent of total billed charges 5.2 8.03 80% of billed charge TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC outpatient 100 ME 9.45 7.56 Cigna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55% of Billed Charges TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC inpatient 100 ME 9.45 4.73 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 4.73 8.03 Inpatient Reimbursement at 85% of Billed Charges TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC outpatient 100 ME 9.45 7.56 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 5.2 8.03 Reimbursement at 85% of billed charges TRANEXAMIC ACID 100MG/ML 10ML VIAL 260 RC 2315552441 NDC outpatient 100 ME 9.45 7.56 Aetna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55 of billed Charges BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC inpatient 32 F2 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC outpatient 32 F2 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC outpatient 32 F2 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC inpatient 32 F2 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC outpatient 32 F2 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BACITRACIN OINT 1/32OZ. PACKET 250 RC 4580206070 NDC outpatient 32 F2 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC inpatient 25 ME 7.06 3.53 BCBS Louisiana PPO 3.53 percent of total billed charges 3.53 6 50% of Eligible Charges CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC outpatient 25 ME 7.06 5.65 BCBS Louisiana PPO 5.65 percent of total billed charges 3.88 6 80% of billed charge CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC outpatient 25 ME 7.06 5.65 Cigna Commercial PPO 3.88 percent of total billed charges 3.88 6 55% of Billed Charges CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC inpatient 25 ME 7.06 3.53 IMA of Louisiana Commercial PPO 6 percent of total billed charges 3.53 6 Inpatient Reimbursement at 85% of Billed Charges CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC outpatient 25 ME 7.06 5.65 IMA of Louisiana Commercial PPO 6 percent of total billed charges 3.88 6 Reimbursement at 85% of billed charges CHLORTHALIDONE 25MG TABLET 250 RC 5107905801 NDC outpatient 25 ME 7.06 5.65 Aetna Commercial PPO 3.88 percent of total billed charges 3.88 6 55 of billed Charges BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BUSPIRONE HCL 5MG TAB 250 RC 5107998520 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PROPOFOL 10MG/ML 100ML J2704 HCPCS 636 RC 6332326969 NDC inpatient 10 ME 63.11 31.56 BCBS Louisiana PPO 31.56 percent of total billed charges 31.56 53.64 50% of Eligible Charges PROPOFOL 10MG/ML 100ML J2704 HCPCS 636 RC 6332326969 NDC outpatient 10 ME 63.11 50.49 BCBS Louisiana PPO 50.49 percent of total billed charges 34.71 53.64 80% of billed charge PROPOFOL 10MG/ML 100ML J2704 HCPCS 636 RC 6332326969 NDC outpatient 10 ME 63.11 50.49 Cigna Commercial PPO 34.71 percent of total billed charges 34.71 53.64 55% of Billed Charges PROPOFOL 10MG/ML 100ML J2704 HCPCS 636 RC 6332326969 NDC inpatient 10 ME 63.11 31.56 IMA of Louisiana Commercial PPO 53.64 percent of total billed charges 31.56 53.64 Inpatient Reimbursement at 85% of Billed Charges PROPOFOL 10MG/ML 100ML J2704 HCPCS 636 RC 6332326969 NDC outpatient 10 ME 63.11 50.49 IMA of Louisiana Commercial PPO 53.64 percent of total billed charges 34.71 53.64 Reimbursement at 85% of billed charges FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC inpatient 40 ME 1.92 0.96 BCBS Louisiana PPO 0.96 percent of total billed charges 0.96 1.63 50% of Eligible Charges FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC outpatient 40 ME 1.92 1.54 BCBS Louisiana PPO 1.54 percent of total billed charges 1.06 1.63 80% of billed charge FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC outpatient 40 ME 1.92 1.54 Cigna Commercial PPO 1.06 percent of total billed charges 1.06 1.63 55% of Billed Charges FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC inpatient 40 ME 1.92 0.96 IMA of Louisiana Commercial PPO 1.63 percent of total billed charges 0.96 1.63 Inpatient Reimbursement at 85% of Billed Charges FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC outpatient 40 ME 1.92 1.54 IMA of Louisiana Commercial PPO 1.63 percent of total billed charges 1.06 1.63 Reimbursement at 85% of billed charges FEBUXOSTAT 40MG TABLET 250 RC 5965111330 NDC outpatient 40 ME 1.92 1.54 Aetna Commercial PPO 1.06 percent of total billed charges 1.06 1.63 55 of billed Charges TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC inpatient 75 ME 81.92 40.96 BCBS Louisiana PPO 40.96 percent of total billed charges 40.96 69.63 50% of Eligible Charges TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC outpatient 75 ME 81.92 65.54 BCBS Louisiana PPO 65.54 percent of total billed charges 45.06 69.63 80% of billed charge TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC outpatient 75 ME 81.92 65.54 Cigna Commercial PPO 45.06 percent of total billed charges 45.06 69.63 55% of Billed Charges TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC inpatient 75 ME 81.92 40.96 IMA of Louisiana Commercial PPO 69.63 percent of total billed charges 40.96 69.63 Inpatient Reimbursement at 85% of Billed Charges TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC outpatient 75 ME 81.92 65.54 IMA of Louisiana Commercial PPO 69.63 percent of total billed charges 45.06 69.63 Reimbursement at 85% of billed charges TAPENTADOL 75MG TABLET 250 RC 2451007510 NDC outpatient 75 ME 81.92 65.54 Aetna Commercial PPO 45.06 percent of total billed charges 45.06 69.63 55 of billed Charges LIBRIUM 5MG CAP NON-FORMULARY J8499 HCPCS 250 RC 0555015802 NDC inpatient 5 ME 15.63 7.82 BCBS Louisiana PPO 7.82 percent of total billed charges 7.82 13.29 50% of Eligible Charges LIBRIUM 5MG CAP NON-FORMULARY J8499 HCPCS 250 RC 0555015802 NDC outpatient 5 ME 15.63 12.5 BCBS Louisiana PPO 12.5 percent of total billed charges 8.6 13.29 80% of billed charge LIBRIUM 5MG CAP NON-FORMULARY J8499 HCPCS 250 RC 0555015802 NDC outpatient 5 ME 15.63 12.5 Cigna Commercial PPO 8.6 percent of total billed charges 8.6 13.29 55% of Billed Charges LIBRIUM 5MG CAP NON-FORMULARY J8499 HCPCS 250 RC 0555015802 NDC inpatient 5 ME 15.63 7.82 IMA of Louisiana Commercial PPO 13.29 percent of total billed charges 7.82 13.29 Inpatient Reimbursement at 85% of Billed Charges LIBRIUM 5MG CAP NON-FORMULARY J8499 HCPCS 250 RC 0555015802 NDC outpatient 5 ME 15.63 12.5 IMA of Louisiana Commercial PPO 13.29 percent of total billed charges 8.6 13.29 Reimbursement at 85% of billed charges METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC inpatient 250 ME 1.94 0.97 BCBS Louisiana PPO 0.97 percent of total billed charges 0.97 1.65 50% of Eligible Charges METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC outpatient 250 ME 1.94 1.55 BCBS Louisiana PPO 1.55 percent of total billed charges 1.07 1.65 80% of billed charge METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC outpatient 250 ME 1.94 1.55 Cigna Commercial PPO 1.07 percent of total billed charges 1.07 1.65 55% of Billed Charges METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC inpatient 250 ME 1.94 0.97 IMA of Louisiana Commercial PPO 1.65 percent of total billed charges 0.97 1.65 Inpatient Reimbursement at 85% of Billed Charges METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC outpatient 250 ME 1.94 1.55 IMA of Louisiana Commercial PPO 1.65 percent of total billed charges 1.07 1.65 Reimbursement at 85% of billed charges METHYLDOPA 250MG TAB NON-FORMULARY 250 RC 0378061101 NDC outpatient 250 ME 1.94 1.55 Aetna Commercial PPO 1.07 percent of total billed charges 1.07 1.65 55 of billed Charges ALBUTEROL 0.083% INH 3ML NON-FORMULARY J8499 HCPCS 250 RC 0487950103 NDC inpatient 3 ML 73.73 36.87 BCBS Louisiana PPO 36.87 percent of total billed charges 36.87 62.67 50% of Eligible Charges ALBUTEROL 0.083% INH 3ML NON-FORMULARY J8499 HCPCS 250 RC 0487950103 NDC outpatient 3 ML 73.73 58.98 BCBS Louisiana PPO 58.98 percent of total billed charges 40.55 62.67 80% of billed charge ALBUTEROL 0.083% INH 3ML NON-FORMULARY J8499 HCPCS 250 RC 0487950103 NDC outpatient 3 ML 73.73 58.98 Cigna Commercial PPO 40.55 percent of total billed charges 40.55 62.67 55% of Billed Charges ALBUTEROL 0.083% INH 3ML NON-FORMULARY J8499 HCPCS 250 RC 0487950103 NDC inpatient 3 ML 73.73 36.87 IMA of Louisiana Commercial PPO 62.67 percent of total billed charges 36.87 62.67 Inpatient Reimbursement at 85% of Billed Charges ALBUTEROL 0.083% INH 3ML NON-FORMULARY J8499 HCPCS 250 RC 0487950103 NDC outpatient 3 ML 73.73 58.98 IMA of Louisiana Commercial PPO 62.67 percent of total billed charges 40.55 62.67 Reimbursement at 85% of billed charges BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BENZONATATE 100MG CAP NON-FORMULARY 250 RC 6438071206 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC inpatient 20 ML 14.4 7.2 BCBS Louisiana PPO 7.2 percent of total billed charges 7.2 12.24 50% of Eligible Charges ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC outpatient 20 ML 14.4 11.52 BCBS Louisiana PPO 11.52 percent of total billed charges 7.92 12.24 80% of billed charge ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC outpatient 20 ML 14.4 11.52 Cigna Commercial PPO 7.92 percent of total billed charges 7.92 12.24 55% of Billed Charges ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC inpatient 20 ML 14.4 7.2 IMA of Louisiana Commercial PPO 12.24 percent of total billed charges 7.2 12.24 Inpatient Reimbursement at 85% of Billed Charges ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC outpatient 20 ML 14.4 11.52 IMA of Louisiana Commercial PPO 12.24 percent of total billed charges 7.92 12.24 Reimbursement at 85% of billed charges ROPIVACAINE 0.2% 10ML NON-FORMULARY 250 RC 5515019720 NDC outpatient 20 ML 14.4 11.52 Aetna Commercial PPO 7.92 percent of total billed charges 7.92 12.24 55 of billed Charges METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METOPROLOL TART 25MG TABLET 250 RC 5009050700 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC inpatient 25 ME 88.38 44.19 BCBS Louisiana PPO 44.19 percent of total billed charges 44.19 75.12 50% of Eligible Charges MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC outpatient 25 ME 88.38 70.7 BCBS Louisiana PPO 70.7 percent of total billed charges 48.61 75.12 80% of billed charge MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC outpatient 25 ME 88.38 70.7 Cigna Commercial PPO 48.61 percent of total billed charges 48.61 75.12 55% of Billed Charges MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC inpatient 25 ME 88.38 44.19 IMA of Louisiana Commercial PPO 75.12 percent of total billed charges 44.19 75.12 Inpatient Reimbursement at 85% of Billed Charges MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC outpatient 25 ME 88.38 70.7 IMA of Louisiana Commercial PPO 75.12 percent of total billed charges 48.61 75.12 Reimbursement at 85% of billed charges MYRBETRIQ ER 25MG TABLET 250 RC 0486130019 NDC outpatient 25 ME 88.38 70.7 Aetna Commercial PPO 48.61 percent of total billed charges 48.61 75.12 55 of billed Charges ENOXAPARIN 100MG/1ML NON-FORMULARY J8499 HCPCS 250 RC 6332358696 NDC inpatient 100 ME 55.92 27.96 BCBS Louisiana PPO 27.96 percent of total billed charges 27.96 47.53 50% of Eligible Charges ENOXAPARIN 100MG/1ML NON-FORMULARY J8499 HCPCS 250 RC 6332358696 NDC outpatient 100 ME 55.92 44.74 BCBS Louisiana PPO 44.74 percent of total billed charges 30.76 47.53 80% of billed charge ENOXAPARIN 100MG/1ML NON-FORMULARY J8499 HCPCS 250 RC 6332358696 NDC outpatient 100 ME 55.92 44.74 Cigna Commercial PPO 30.76 percent of total billed charges 30.76 47.53 55% of Billed Charges ENOXAPARIN 100MG/1ML NON-FORMULARY J8499 HCPCS 250 RC 6332358696 NDC inpatient 100 ME 55.92 27.96 IMA of Louisiana Commercial PPO 47.53 percent of total billed charges 27.96 47.53 Inpatient Reimbursement at 85% of Billed Charges ENOXAPARIN 100MG/1ML NON-FORMULARY J8499 HCPCS 250 RC 6332358696 NDC outpatient 100 ME 55.92 44.74 IMA of Louisiana Commercial PPO 47.53 percent of total billed charges 30.76 47.53 Reimbursement at 85% of billed charges TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC inpatient 30 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC outpatient 30 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC outpatient 30 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC inpatient 30 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC outpatient 30 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TYLENOL #3 TAB NON-FORMULARY 250 RC 0406048462 NDC outpatient 30 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC inpatient 60 ME 1.45 0.73 BCBS Louisiana PPO 0.73 percent of total billed charges 0.73 1.23 50% of Eligible Charges ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC outpatient 60 ME 1.45 1.16 BCBS Louisiana PPO 1.16 percent of total billed charges 0.8 1.23 80% of billed charge ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC outpatient 60 ME 1.45 1.16 Cigna Commercial PPO 0.8 percent of total billed charges 0.8 1.23 55% of Billed Charges ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC inpatient 60 ME 1.45 0.73 IMA of Louisiana Commercial PPO 1.23 percent of total billed charges 0.73 1.23 Inpatient Reimbursement at 85% of Billed Charges ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC outpatient 60 ME 1.45 1.16 IMA of Louisiana Commercial PPO 1.23 percent of total billed charges 0.8 1.23 Reimbursement at 85% of billed charges ARMOUR THYROID 60MG TABLET 250 RC 0474710018 NDC outpatient 60 ME 1.45 1.16 Aetna Commercial PPO 0.8 percent of total billed charges 0.8 1.23 55 of billed Charges SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC inpatient 50 ML 12.21 6.11 BCBS Louisiana PPO 6.11 percent of total billed charges 6.11 10.38 50% of Eligible Charges SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC outpatient 50 ML 12.21 9.77 BCBS Louisiana PPO 9.77 percent of total billed charges 6.72 10.38 80% of billed charge SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC outpatient 50 ML 12.21 9.77 Cigna Commercial PPO 6.72 percent of total billed charges 6.72 10.38 55% of Billed Charges SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC inpatient 50 ML 12.21 6.11 IMA of Louisiana Commercial PPO 10.38 percent of total billed charges 6.11 10.38 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC outpatient 50 ML 12.21 9.77 IMA of Louisiana Commercial PPO 10.38 percent of total billed charges 6.72 10.38 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 50ML PF 260 RC 0409488806 NDC outpatient 50 ML 12.21 9.77 Aetna Commercial PPO 6.72 percent of total billed charges 6.72 10.38 55 of billed Charges TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC inpatient 650 ME 7.99 4 BCBS Louisiana PPO 4 percent of total billed charges 4 6.79 50% of Eligible Charges TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC outpatient 650 ME 7.99 6.39 BCBS Louisiana PPO 6.39 percent of total billed charges 4.39 6.79 80% of billed charge TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC outpatient 650 ME 7.99 6.39 Cigna Commercial PPO 4.39 percent of total billed charges 4.39 6.79 55% of Billed Charges TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC inpatient 650 ME 7.99 4 IMA of Louisiana Commercial PPO 6.79 percent of total billed charges 4 6.79 Inpatient Reimbursement at 85% of Billed Charges TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC outpatient 650 ME 7.99 6.39 IMA of Louisiana Commercial PPO 6.79 percent of total billed charges 4.39 6.79 Reimbursement at 85% of billed charges TRANEXAMIC ACID 650MG TAB NON-FORMULARY 250 RC 6991830130 NDC outpatient 650 ME 7.99 6.39 Aetna Commercial PPO 4.39 percent of total billed charges 4.39 6.79 55 of billed Charges AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC inpatient 500 ME 13.18 6.59 BCBS Louisiana PPO 6.59 percent of total billed charges 6.59 11.2 50% of Eligible Charges AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC outpatient 500 ME 13.18 10.54 BCBS Louisiana PPO 10.54 percent of total billed charges 7.25 11.2 80% of billed charge AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC outpatient 500 ME 13.18 10.54 Cigna Commercial PPO 7.25 percent of total billed charges 7.25 11.2 55% of Billed Charges AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC inpatient 500 ME 13.18 6.59 IMA of Louisiana Commercial PPO 11.2 percent of total billed charges 6.59 11.2 Inpatient Reimbursement at 85% of Billed Charges AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC outpatient 500 ME 13.18 10.54 IMA of Louisiana Commercial PPO 11.2 percent of total billed charges 7.25 11.2 Reimbursement at 85% of billed charges AMPICILLIN 500MG IVPB NON-FORMULARY 260 RC 5515011720 NDC outpatient 500 ME 13.18 10.54 Aetna Commercial PPO 7.25 percent of total billed charges 7.25 11.2 55 of billed Charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges CRTJ SHUNT VENTRICULO-PRTL-PLEURAL OTH 29870 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC inpatient 13175.08 6587.54 BCBS Louisiana PPO 6587.54 percent of total billed charges 6587.54 11198.82 50% of Eligible Charges SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC outpatient 13175.08 10540.06 BCBS Louisiana PPO 10540.06 percent of total billed charges 1300 11198.82 80% of billed charges SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC outpatient 13175.08 10540.06 Cigna Commercial PPO 7246.29 percent of total billed charges 1300 11198.82 55% of Billed Charges SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC inpatient 13175.08 6587.54 IMA of Louisiana Commercial PPO 11198.82 percent of total billed charges 6587.54 11198.82 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC outpatient 13175.08 10540.06 IMA of Louisiana Commercial PPO 11198.82 percent of total billed charges 1300 11198.82 Reimbursement at 85% of billed charges SHOULDER ARTHROSCOPY/SURGERY 29806 CPT 360 RC outpatient 13175.08 10540.06 Aetna Commercial PPO 1300 fee schedule 1300 11198.82 Case Rate KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC inpatient 4430.75 2215.38 BCBS Louisiana PPO 2215.38 percent of total billed charges 2215.38 3766.14 50% of Eligible Charges KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC outpatient 4430.75 3544.6 BCBS Louisiana PPO 3544.6 percent of total billed charges 1300 3766.14 80% of billed charges KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC outpatient 4430.75 3544.6 Cigna Commercial PPO 2436.91 percent of total billed charges 1300 3766.14 55% of Billed Charges KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC inpatient 4430.75 2215.38 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 2215.38 3766.14 Inpatient Reimbursement at 85% of Billed Charges KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC outpatient 4430.75 3544.6 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 1300 3766.14 Reimbursement at 85% of billed charges KNEE ARTHROSCOPY/SURGERY 29873 CPT 360 RC outpatient 4430.75 3544.6 Aetna Commercial PPO 1300 fee schedule 1300 3766.14 Case Rate ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 1300 11913.64 55% of Billed Charges ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges ANDLE ARTHROSCOPY/SURGERY 29892 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges INJECT FOR SPINE DISK X-RAY 62290 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges REMOVAL OF SPINAL LAMINA 63001 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate LOW BACK DISK SURGERY 63030 CPT 360 RC inpatient 13735.73 6867.87 BCBS Louisiana PPO 6867.87 percent of total billed charges 6867.87 11675.37 50% of Eligible Charges LOW BACK DISK SURGERY 63030 CPT 360 RC outpatient 13735.73 10988.58 BCBS Louisiana PPO 10988.58 percent of total billed charges 1300 11675.37 80% of billed charges LOW BACK DISK SURGERY 63030 CPT 360 RC outpatient 13735.73 10988.58 Cigna Commercial PPO 6800 case rate 1300 11675.37 6800 case rate LOW BACK DISK SURGERY 63030 CPT 360 RC inpatient 13735.73 6867.87 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 6867.87 11675.37 Inpatient Reimbursement at 85% of Billed Charges LOW BACK DISK SURGERY 63030 CPT 360 RC outpatient 13735.73 10988.58 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 1300 11675.37 Reimbursement at 85% of billed charges LOW BACK DISK SURGERY 63030 CPT 360 RC outpatient 13735.73 10988.58 Aetna Commercial PPO 1300 fee schedule 1300 11675.37 Case Rate EXCISE INTRASPINAL LESION 63267 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges EXCISE INTRASPINAL LESION 63267 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges EXCISE INTRASPINAL LESION 63267 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate EXCISE INTRASPINAL LESION 63267 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges EXCISE INTRASPINAL LESION 63267 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges EXCISE INTRASPINAL LESION 63267 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC inpatient 418.1 209.05 BCBS Louisiana PPO 209.05 percent of total billed charges 209.05 355.39 50% of Eligible Charges INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC outpatient 418.1 334.48 BCBS Louisiana PPO 334.48 percent of total billed charges 229.96 1300 80% of billed charges INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC outpatient 418.1 334.48 Cigna Commercial PPO 229.96 percent of total billed charges 229.96 1300 55% of Billed Charges INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC inpatient 418.1 209.05 IMA of Louisiana Commercial PPO 355.39 percent of total billed charges 209.05 355.39 Inpatient Reimbursement at 85% of Billed Charges INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC outpatient 418.1 334.48 IMA of Louisiana Commercial PPO 355.39 percent of total billed charges 229.96 1300 Reimbursement at 85% of billed charges INJ FORAMEN EPIDURAL ADD-ON 64480 CPT 360 RC outpatient 418.1 334.48 Aetna Commercial PPO 1300 fee schedule 229.96 1300 Case Rate REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges REVISE ULNAR NERVE AT WRIST 64719 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC inpatient 13735.73 6867.87 BCBS Louisiana PPO 6867.87 percent of total billed charges 6867.87 11675.37 50% of Eligible Charges LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC outpatient 13735.73 10988.58 BCBS Louisiana PPO 10988.58 percent of total billed charges 1300 11675.37 80% of billed charges LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC outpatient 13735.73 10988.58 Cigna Commercial PPO 6800 case rate 1300 11675.37 6800 case rate LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC inpatient 13735.73 6867.87 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 6867.87 11675.37 Inpatient Reimbursement at 85% of Billed Charges LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC outpatient 13735.73 10988.58 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 1300 11675.37 Reimbursement at 85% of billed charges LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC 63012 CPT 360 RC outpatient 13735.73 10988.58 Aetna Commercial PPO 1300 fee schedule 1300 11675.37 Case Rate NJX ANES FEM NERVE 1 64447 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges NJX ANES FEM NERVE 1 64447 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 100 1154.68 80% of billed charges NJX ANES FEM NERVE 1 64447 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 100 1154.68 55% of Billed Charges NJX ANES FEM NERVE 1 64447 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges NJX ANES FEM NERVE 1 64447 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 100 1154.68 Reimbursement at 85% of billed charges NJX ANES FEM NERVE 1 64447 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 100 fee schedule 100 1154.68 Case Rate REPAIR OF BLOOD VESSEL 35221 CPT 360 RC inpatient 6231.85 3115.93 BCBS Louisiana PPO 3115.93 percent of total billed charges 3115.93 5297.07 50% of Eligible Charges REPAIR OF BLOOD VESSEL 35221 CPT 360 RC outpatient 6231.85 4985.48 BCBS Louisiana PPO 4985.48 percent of total billed charges 100 5297.07 80% of billed charges REPAIR OF BLOOD VESSEL 35221 CPT 360 RC outpatient 6231.85 4985.48 Cigna Commercial PPO 3427.52 percent of total billed charges 100 5297.07 55% of Billed Charges REPAIR OF BLOOD VESSEL 35221 CPT 360 RC inpatient 6231.85 3115.93 IMA of Louisiana Commercial PPO 5297.07 percent of total billed charges 3115.93 5297.07 Inpatient Reimbursement at 85% of Billed Charges REPAIR OF BLOOD VESSEL 35221 CPT 360 RC outpatient 6231.85 4985.48 IMA of Louisiana Commercial PPO 5297.07 percent of total billed charges 100 5297.07 Reimbursement at 85% of billed charges REPAIR OF BLOOD VESSEL 35221 CPT 360 RC outpatient 6231.85 4985.48 Aetna Commercial PPO 100 fee schedule 100 5297.07 Case Rate NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC inpatient 1208 604 BCBS Louisiana PPO 604 percent of total billed charges 604 1026.8 50% of Eligible Charges NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC outpatient 1208 966.4 BCBS Louisiana PPO 966.4 percent of total billed charges 664.4 1300 80% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC outpatient 1208 966.4 Cigna Commercial PPO 664.4 percent of total billed charges 664.4 1300 55% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC inpatient 1208 604 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 604 1026.8 Inpatient Reimbursement at 85% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC outpatient 1208 966.4 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 664.4 1300 Reimbursement at 85% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 2 64494 CPT 360 RC outpatient 1208 966.4 Aetna Commercial PPO 1300 fee schedule 664.4 1300 Case Rate NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC inpatient 1208 604 BCBS Louisiana PPO 604 percent of total billed charges 604 1026.8 50% of Eligible Charges NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC outpatient 1208 966.4 BCBS Louisiana PPO 966.4 percent of total billed charges 664.4 1300 80% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC outpatient 1208 966.4 Cigna Commercial PPO 664.4 percent of total billed charges 664.4 1300 55% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC inpatient 1208 604 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 604 1026.8 Inpatient Reimbursement at 85% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC outpatient 1208 966.4 IMA of Louisiana Commercial PPO 1026.8 percent of total billed charges 664.4 1300 Reimbursement at 85% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 3 64495 CPT 360 RC outpatient 1208 966.4 Aetna Commercial PPO 1300 fee schedule 664.4 1300 Case Rate ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC inpatient 357.49 178.75 BCBS Louisiana PPO 178.75 percent of total billed charges 178.75 303.87 50% of Eligible Charges ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC outpatient 357.49 285.99 BCBS Louisiana PPO 285.99 percent of total billed charges 196.62 303.87 80% of billed charge ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC outpatient 357.49 285.99 Cigna Commercial PPO 196.62 percent of total billed charges 196.62 303.87 55% of Billed Charges ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC inpatient 357.49 178.75 IMA of Louisiana Commercial PPO 303.87 percent of total billed charges 178.75 303.87 Inpatient Reimbursement at 85% of Billed Charges ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC outpatient 357.49 285.99 IMA of Louisiana Commercial PPO 303.87 percent of total billed charges 196.62 303.87 Reimbursement at 85% of billed charges ANSPACH EMAX 2 IRR. CLIP - MAKO 272 RC outpatient 357.49 285.99 Aetna Commercial PPO 196.62 percent of total billed charges 196.62 303.87 55 of billed Charges SILICON RETRACTOR SET - STRYKER ORTHO 272 RC inpatient 22.68 11.34 BCBS Louisiana PPO 11.34 percent of total billed charges 11.34 19.28 50% of Eligible Charges SILICON RETRACTOR SET - STRYKER ORTHO 272 RC outpatient 22.68 18.14 BCBS Louisiana PPO 18.14 percent of total billed charges 12.47 19.28 80% of billed charge SILICON RETRACTOR SET - STRYKER ORTHO 272 RC outpatient 22.68 18.14 Cigna Commercial PPO 12.47 percent of total billed charges 12.47 19.28 55% of Billed Charges SILICON RETRACTOR SET - STRYKER ORTHO 272 RC inpatient 22.68 11.34 IMA of Louisiana Commercial PPO 19.28 percent of total billed charges 11.34 19.28 Inpatient Reimbursement at 85% of Billed Charges SILICON RETRACTOR SET - STRYKER ORTHO 272 RC outpatient 22.68 18.14 IMA of Louisiana Commercial PPO 19.28 percent of total billed charges 12.47 19.28 Reimbursement at 85% of billed charges SILICON RETRACTOR SET - STRYKER ORTHO 272 RC outpatient 22.68 18.14 Aetna Commercial PPO 12.47 percent of total billed charges 12.47 19.28 55 of billed Charges FOOT DROP BRACE AFO R/L 270 RC inpatient 86.6 43.3 BCBS Louisiana PPO 43.3 percent of total billed charges 43.3 73.61 50% of Eligible Charges FOOT DROP BRACE AFO R/L 270 RC outpatient 86.6 69.28 BCBS Louisiana PPO 69.28 percent of total billed charges 47.63 73.61 80% of billed charge FOOT DROP BRACE AFO R/L 270 RC outpatient 86.6 69.28 Cigna Commercial PPO 47.63 percent of total billed charges 47.63 73.61 55% of Billed Charges FOOT DROP BRACE AFO R/L 270 RC inpatient 86.6 43.3 IMA of Louisiana Commercial PPO 73.61 percent of total billed charges 43.3 73.61 Inpatient Reimbursement at 85% of Billed Charges FOOT DROP BRACE AFO R/L 270 RC outpatient 86.6 69.28 IMA of Louisiana Commercial PPO 73.61 percent of total billed charges 47.63 73.61 Reimbursement at 85% of billed charges FOOT DROP BRACE AFO R/L 270 RC outpatient 86.6 69.28 Aetna Commercial PPO 47.63 percent of total billed charges 47.63 73.61 55 of billed Charges DEPENDS BRIEF - 2XLARGE 270 RC inpatient 2 1 BCBS Louisiana PPO 1 percent of total billed charges 1 1.7 50% of Eligible Charges DEPENDS BRIEF - 2XLARGE 270 RC outpatient 2 1.6 BCBS Louisiana PPO 1.6 percent of total billed charges 1.1 1.7 80% of billed charge DEPENDS BRIEF - 2XLARGE 270 RC outpatient 2 1.6 Cigna Commercial PPO 1.1 percent of total billed charges 1.1 1.7 55% of Billed Charges DEPENDS BRIEF - 2XLARGE 270 RC inpatient 2 1 IMA of Louisiana Commercial PPO 1.7 percent of total billed charges 1 1.7 Inpatient Reimbursement at 85% of Billed Charges DEPENDS BRIEF - 2XLARGE 270 RC outpatient 2 1.6 IMA of Louisiana Commercial PPO 1.7 percent of total billed charges 1.1 1.7 Reimbursement at 85% of billed charges DEPENDS BRIEF - 2XLARGE 270 RC outpatient 2 1.6 Aetna Commercial PPO 1.1 percent of total billed charges 1.1 1.7 55 of billed Charges EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC inpatient 590 295 BCBS Louisiana PPO 295 percent of total billed charges 295 501.5 50% of Eligible Charges EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC outpatient 590 472 BCBS Louisiana PPO 472 percent of total billed charges 324.5 501.5 80% of billed charge EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC outpatient 590 472 Cigna Commercial PPO 324.5 percent of total billed charges 324.5 501.5 55% of Billed Charges EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC inpatient 590 295 IMA of Louisiana Commercial PPO 501.5 percent of total billed charges 295 501.5 Inpatient Reimbursement at 85% of Billed Charges EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC outpatient 590 472 IMA of Louisiana Commercial PPO 501.5 percent of total billed charges 324.5 501.5 Reimbursement at 85% of billed charges EXTRACTOR STRIPPED SCREW 2.0-2.5MM 272 RC outpatient 590 472 Aetna Commercial PPO 324.5 percent of total billed charges 324.5 501.5 55 of billed Charges FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC inpatient 540 270 BCBS Louisiana PPO 270 percent of total billed charges 270 459 50% of Eligible Charges FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC outpatient 540 432 BCBS Louisiana PPO 432 percent of total billed charges 297 459 80% of billed charge FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC outpatient 540 432 Cigna Commercial PPO 297 percent of total billed charges 297 459 55% of Billed Charges FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC inpatient 540 270 IMA of Louisiana Commercial PPO 459 percent of total billed charges 270 459 Inpatient Reimbursement at 85% of Billed Charges FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC outpatient 540 432 IMA of Louisiana Commercial PPO 459 percent of total billed charges 297 459 Reimbursement at 85% of billed charges FULL RADIUS 2.9MM MAG-MINI - S&N ENDO 272 RC outpatient 540 432 Aetna Commercial PPO 297 percent of total billed charges 297 459 55 of billed Charges INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC inpatient 540 270 BCBS Louisiana PPO 270 percent of total billed charges 270 459 50% of Eligible Charges INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC outpatient 540 432 BCBS Louisiana PPO 432 percent of total billed charges 297 459 80% of billed charge INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC outpatient 540 432 Cigna Commercial PPO 297 percent of total billed charges 297 459 55% of Billed Charges INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC inpatient 540 270 IMA of Louisiana Commercial PPO 459 percent of total billed charges 270 459 Inpatient Reimbursement at 85% of Billed Charges INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC outpatient 540 432 IMA of Louisiana Commercial PPO 459 percent of total billed charges 297 459 Reimbursement at 85% of billed charges INCISOR PLUS ELITE MINI 2.9MM - S&N ENDO 272 RC outpatient 540 432 Aetna Commercial PPO 297 percent of total billed charges 297 459 55 of billed Charges DISTRACTION PIN 12MM 272 RC inpatient 562.5 281.25 BCBS Louisiana PPO 281.25 percent of total billed charges 281.25 478.13 50% of Eligible Charges DISTRACTION PIN 12MM 272 RC outpatient 562.5 450 BCBS Louisiana PPO 450 percent of total billed charges 309.38 478.13 80% of billed charge DISTRACTION PIN 12MM 272 RC outpatient 562.5 450 Cigna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55% of Billed Charges DISTRACTION PIN 12MM 272 RC inpatient 562.5 281.25 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 281.25 478.13 Inpatient Reimbursement at 85% of Billed Charges DISTRACTION PIN 12MM 272 RC outpatient 562.5 450 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 309.38 478.13 Reimbursement at 85% of billed charges DISTRACTION PIN 12MM 272 RC outpatient 562.5 450 Aetna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55 of billed Charges COAGUCHEK XS TEST STRIP 270 RC inpatient 22.64 11.32 BCBS Louisiana PPO 11.32 percent of total billed charges 11.32 19.24 50% of Eligible Charges COAGUCHEK XS TEST STRIP 270 RC outpatient 22.64 18.11 BCBS Louisiana PPO 18.11 percent of total billed charges 12.45 19.24 80% of billed charge COAGUCHEK XS TEST STRIP 270 RC outpatient 22.64 18.11 Cigna Commercial PPO 12.45 percent of total billed charges 12.45 19.24 55% of Billed Charges COAGUCHEK XS TEST STRIP 270 RC inpatient 22.64 11.32 IMA of Louisiana Commercial PPO 19.24 percent of total billed charges 11.32 19.24 Inpatient Reimbursement at 85% of Billed Charges COAGUCHEK XS TEST STRIP 270 RC outpatient 22.64 18.11 IMA of Louisiana Commercial PPO 19.24 percent of total billed charges 12.45 19.24 Reimbursement at 85% of billed charges COAGUCHEK XS TEST STRIP 270 RC outpatient 22.64 18.11 Aetna Commercial PPO 12.45 percent of total billed charges 12.45 19.24 55 of billed Charges CARBOJET CO2 BONE PREP 272 RC inpatient 1006.25 503.13 BCBS Louisiana PPO 503.13 percent of total billed charges 503.13 855.31 50% of Eligible Charges CARBOJET CO2 BONE PREP 272 RC outpatient 1006.25 805 BCBS Louisiana PPO 805 percent of total billed charges 553.44 855.31 80% of billed charge CARBOJET CO2 BONE PREP 272 RC outpatient 1006.25 805 Cigna Commercial PPO 553.44 percent of total billed charges 553.44 855.31 55% of Billed Charges CARBOJET CO2 BONE PREP 272 RC inpatient 1006.25 503.13 IMA of Louisiana Commercial PPO 855.31 percent of total billed charges 503.13 855.31 Inpatient Reimbursement at 85% of Billed Charges CARBOJET CO2 BONE PREP 272 RC outpatient 1006.25 805 IMA of Louisiana Commercial PPO 855.31 percent of total billed charges 553.44 855.31 Reimbursement at 85% of billed charges CARBOJET CO2 BONE PREP 272 RC outpatient 1006.25 805 Aetna Commercial PPO 553.44 percent of total billed charges 553.44 855.31 55 of billed Charges ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC inpatient 250.08 125.04 BCBS Louisiana PPO 125.04 percent of total billed charges 125.04 212.57 50% of Eligible Charges ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC outpatient 250.08 200.06 BCBS Louisiana PPO 200.06 percent of total billed charges 92.53 212.57 80% of billed charge ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC outpatient 250.08 200.06 Cigna Commercial PPO 145.05 percent of total billed charges 92.53 212.57 58% of Billed Charges/$500 Threshold ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC inpatient 250.08 125.04 IMA of Louisiana Commercial PPO 212.57 percent of total billed charges 125.04 212.57 Inpatient Reimbursement at 85% of Billed Charges ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC outpatient 250.08 200.06 IMA of Louisiana Commercial PPO 212.57 percent of total billed charges 92.53 212.57 Reimbursement at 85% of billed charges ROD THREADED 250MM LONG - ATCHISON C1713 HCPCS 278 RC outpatient 250.08 200.06 Aetna Commercial PPO 92.53 percent of total billed charges 92.53 212.57 37% Of Billed Charges 2000 DOUBLE NELSON EXTENSION SET 272 RC inpatient 385.7 192.85 BCBS Louisiana PPO 192.85 percent of total billed charges 192.85 327.85 50% of Eligible Charges DOUBLE NELSON EXTENSION SET 272 RC outpatient 385.7 308.56 BCBS Louisiana PPO 308.56 percent of total billed charges 212.14 327.85 80% of billed charge DOUBLE NELSON EXTENSION SET 272 RC outpatient 385.7 308.56 Cigna Commercial PPO 212.14 percent of total billed charges 212.14 327.85 55% of Billed Charges DOUBLE NELSON EXTENSION SET 272 RC inpatient 385.7 192.85 IMA of Louisiana Commercial PPO 327.85 percent of total billed charges 192.85 327.85 Inpatient Reimbursement at 85% of Billed Charges DOUBLE NELSON EXTENSION SET 272 RC outpatient 385.7 308.56 IMA of Louisiana Commercial PPO 327.85 percent of total billed charges 212.14 327.85 Reimbursement at 85% of billed charges DOUBLE NELSON EXTENSION SET 272 RC outpatient 385.7 308.56 Aetna Commercial PPO 212.14 percent of total billed charges 212.14 327.85 55 of billed Charges TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC inpatient 3000 1500 BCBS Louisiana PPO 1500 percent of total billed charges 1500 2550 50% of Eligible Charges TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC outpatient 3000 2400 BCBS Louisiana PPO 2400 percent of total billed charges 1110 2550 80% of billed charge TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC outpatient 3000 2400 Cigna Commercial PPO 1740 percent of total billed charges 1110 2550 58% of Billed Charges/$500 Threshold TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC inpatient 3000 1500 IMA of Louisiana Commercial PPO 2550 percent of total billed charges 1500 2550 Inpatient Reimbursement at 85% of Billed Charges TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC outpatient 3000 2400 IMA of Louisiana Commercial PPO 2550 percent of total billed charges 1110 2550 Reimbursement at 85% of billed charges TENDON PRE-SUTURED SPEED GRAFT C1713 HCPCS 278 RC outpatient 3000 2400 Aetna Commercial PPO 1110 percent of total billed charges 1110 2550 37% Of Billed Charges 2000 MID LINE PLACEMENT 36569 CPT 360 RC inpatient 2457.43 1228.72 BCBS Louisiana PPO 1228.72 percent of total billed charges 1228.72 2088.82 50% of Eligible Charges MID LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 BCBS Louisiana PPO 1965.94 percent of total billed charges 1300 2088.82 80% of billed charges MID LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 Cigna Commercial PPO 1351.59 percent of total billed charges 1300 2088.82 55% of Billed Charges MID LINE PLACEMENT 36569 CPT 360 RC inpatient 2457.43 1228.72 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1228.72 2088.82 Inpatient Reimbursement at 85% of Billed Charges MID LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 IMA of Louisiana Commercial PPO 2088.82 percent of total billed charges 1300 2088.82 Reimbursement at 85% of billed charges MID LINE PLACEMENT 36569 CPT 360 RC outpatient 2457.43 1965.94 Aetna Commercial PPO 1300 fee schedule 1300 2088.82 Case Rate PROC ROOM SERVICES 08 360 RC inpatient 1762 881 BCBS Louisiana PPO 881 percent of total billed charges 881 1497.7 50% of Eligible Charges PROC ROOM SERVICES 08 360 RC outpatient 1762 1409.6 BCBS Louisiana PPO 1409.6 percent of total billed charges 969.1 1497.7 80% of billed charge PROC ROOM SERVICES 08 360 RC outpatient 1762 1409.6 Cigna Commercial PPO 969.1 percent of total billed charges 969.1 1497.7 55% of Billed Charges PROC ROOM SERVICES 08 360 RC inpatient 1762 881 IMA of Louisiana Commercial PPO 1497.7 percent of total billed charges 881 1497.7 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 08 360 RC outpatient 1762 1409.6 IMA of Louisiana Commercial PPO 1497.7 percent of total billed charges 969.1 1497.7 Reimbursement at 85% of billed charges PROC ROOM SERVICES 08 360 RC outpatient 1762 1409.6 Aetna Commercial PPO 969.1 percent of total billed charges 969.1 1497.7 55 of billed Charges PROC ROOM SERVICES 15 360 RC inpatient 2723 1361.5 BCBS Louisiana PPO 1361.5 percent of total billed charges 1361.5 2314.55 50% of Eligible Charges PROC ROOM SERVICES 15 360 RC outpatient 2723 2178.4 BCBS Louisiana PPO 2178.4 percent of total billed charges 1497.65 2314.55 80% of billed charge PROC ROOM SERVICES 15 360 RC outpatient 2723 2178.4 Cigna Commercial PPO 1497.65 percent of total billed charges 1497.65 2314.55 55% of Billed Charges PROC ROOM SERVICES 15 360 RC inpatient 2723 1361.5 IMA of Louisiana Commercial PPO 2314.55 percent of total billed charges 1361.5 2314.55 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 15 360 RC outpatient 2723 2178.4 IMA of Louisiana Commercial PPO 2314.55 percent of total billed charges 1497.65 2314.55 Reimbursement at 85% of billed charges PROC ROOM SERVICES 15 360 RC outpatient 2723 2178.4 Aetna Commercial PPO 1497.65 percent of total billed charges 1497.65 2314.55 55 of billed Charges PROC ROOM SERVICES 29 360 RC inpatient 15139 7569.5 BCBS Louisiana PPO 7569.5 percent of total billed charges 7569.5 12868.15 50% of Eligible Charges PROC ROOM SERVICES 29 360 RC outpatient 15139 12111.2 BCBS Louisiana PPO 12111.2 percent of total billed charges 8326.45 12868.15 80% of billed charge PROC ROOM SERVICES 29 360 RC outpatient 15139 12111.2 Cigna Commercial PPO 8326.45 percent of total billed charges 8326.45 12868.15 55% of Billed Charges PROC ROOM SERVICES 29 360 RC inpatient 15139 7569.5 IMA of Louisiana Commercial PPO 12868.15 percent of total billed charges 7569.5 12868.15 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 29 360 RC outpatient 15139 12111.2 IMA of Louisiana Commercial PPO 12868.15 percent of total billed charges 8326.45 12868.15 Reimbursement at 85% of billed charges PROC ROOM SERVICES 29 360 RC outpatient 15139 12111.2 Aetna Commercial PPO 8326.45 percent of total billed charges 8326.45 12868.15 55 of billed Charges REC RM 1.0 HR 710 RC inpatient 1050 525 BCBS Louisiana PPO 525 percent of total billed charges 525 892.5 50% of Eligible Charges REC RM 1.0 HR 710 RC outpatient 1050 840 BCBS Louisiana PPO 840 percent of total billed charges 577.5 892.5 80% of billed charge REC RM 1.0 HR 710 RC outpatient 1050 840 Cigna Commercial PPO 577.5 percent of total billed charges 577.5 892.5 55% of Billed Charges REC RM 1.0 HR 710 RC inpatient 1050 525 IMA of Louisiana Commercial PPO 892.5 percent of total billed charges 525 892.5 Inpatient Reimbursement at 85% of Billed Charges REC RM 1.0 HR 710 RC outpatient 1050 840 IMA of Louisiana Commercial PPO 892.5 percent of total billed charges 577.5 892.5 Reimbursement at 85% of billed charges REC RM 1.0 HR 710 RC outpatient 1050 840 Aetna Commercial PPO 577.5 percent of total billed charges 577.5 892.5 55 of billed Charges REC ROOM 7.0 HR 710 RC inpatient 7350 3675 BCBS Louisiana PPO 3675 percent of total billed charges 3675 6247.5 50% of Eligible Charges REC ROOM 7.0 HR 710 RC outpatient 7350 5880 BCBS Louisiana PPO 5880 percent of total billed charges 4042.5 6247.5 80% of billed charge REC ROOM 7.0 HR 710 RC outpatient 7350 5880 Cigna Commercial PPO 4042.5 percent of total billed charges 4042.5 6247.5 55% of Billed Charges REC ROOM 7.0 HR 710 RC inpatient 7350 3675 IMA of Louisiana Commercial PPO 6247.5 percent of total billed charges 3675 6247.5 Inpatient Reimbursement at 85% of Billed Charges REC ROOM 7.0 HR 710 RC outpatient 7350 5880 IMA of Louisiana Commercial PPO 6247.5 percent of total billed charges 4042.5 6247.5 Reimbursement at 85% of billed charges REC ROOM 7.0 HR 710 RC outpatient 7350 5880 Aetna Commercial PPO 4042.5 percent of total billed charges 4042.5 6247.5 55 of billed Charges ALBUMIN 82040 CPT 300 RC inpatient 15.28 7.64 BCBS Louisiana PPO 7.64 percent of total billed charges 7.64 12.99 50% of Eligible Charges ALBUMIN 82040 CPT 300 RC outpatient 15.28 10.7 BCBS Louisiana PPO 10.7 percent of total billed charges 8.4 16.18 70% of billed charges ALBUMIN 82040 CPT 300 RC outpatient 15.28 10.7 Cigna Commercial PPO 8.4 percent of total billed charges 8.4 16.18 55% of Billed Charges ALBUMIN 82040 CPT 300 RC inpatient 15.28 7.64 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 7.64 12.99 Inpatient Reimbursement at 85% of Billed Charges ALBUMIN 82040 CPT 300 RC outpatient 15.28 10.7 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 8.4 16.18 Reimbursement at 85% of billed charges ALBUMIN 82040 CPT 300 RC outpatient 15.28 10.7 Aetna Commercial PPO 16.18 fee schedule 8.4 16.18 200% Of Aetna Market Fee Schedule Hospital Technical Rate CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 BCBS Louisiana PPO 11.99 percent of total billed charges 11.99 20.38 50% of Eligible Charges CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 BCBS Louisiana PPO 16.79 percent of total billed charges 13.19 25.42 70% of billed charges CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Cigna Commercial PPO 13.19 percent of total billed charges 13.19 25.42 55% of Billed Charges CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 11.99 20.38 Inpatient Reimbursement at 85% of Billed Charges CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 13.19 25.42 Reimbursement at 85% of billed charges CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Aetna Commercial PPO 25.42 fee schedule 13.19 25.42 200% Of Aetna Market Fee Schedule Hospital Technical Rate PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 BCBS Louisiana PPO 6.07 percent of total billed charges 6.07 10.31 50% of Eligible Charges PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 BCBS Louisiana PPO 8.49 percent of total billed charges 6.67 12.86 70% of billed charges PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Cigna Commercial PPO 6.67 percent of total billed charges 6.67 12.86 55% of Billed Charges PT W/ INR 85610 CPT 300 RC inpatient 12.13 6.07 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.07 10.31 Inpatient Reimbursement at 85% of Billed Charges PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 IMA of Louisiana Commercial PPO 10.31 percent of total billed charges 6.67 12.86 Reimbursement at 85% of billed charges PT W/ INR 85610 CPT 300 RC outpatient 12.13 8.49 Aetna Commercial PPO 12.86 fee schedule 6.67 12.86 200% Of Aetna Market Fee Schedule Hospital Technical Rate MAGNESIUM 83735 CPT 300 RC inpatient 20.68 10.34 BCBS Louisiana PPO 10.34 percent of total billed charges 10.34 17.58 50% of Eligible Charges MAGNESIUM 83735 CPT 300 RC outpatient 20.68 14.48 BCBS Louisiana PPO 14.48 percent of total billed charges 11.37 21.88 70% of billed charges MAGNESIUM 83735 CPT 300 RC outpatient 20.68 14.48 Cigna Commercial PPO 11.37 percent of total billed charges 11.37 21.88 55% of Billed Charges MAGNESIUM 83735 CPT 300 RC inpatient 20.68 10.34 IMA of Louisiana Commercial PPO 17.58 percent of total billed charges 10.34 17.58 Inpatient Reimbursement at 85% of Billed Charges MAGNESIUM 83735 CPT 300 RC outpatient 20.68 14.48 IMA of Louisiana Commercial PPO 17.58 percent of total billed charges 11.37 21.88 Reimbursement at 85% of billed charges MAGNESIUM 83735 CPT 300 RC outpatient 20.68 14.48 Aetna Commercial PPO 21.88 fee schedule 11.37 21.88 200% Of Aetna Market Fee Schedule Hospital Technical Rate IRON 83540 CPT 301 RC inpatient 19.98 9.99 BCBS Louisiana PPO 9.99 percent of total billed charges 9.99 16.98 50% of Eligible Charges IRON 83540 CPT 301 RC outpatient 19.98 13.99 BCBS Louisiana PPO 13.99 percent of total billed charges 10.99 17.54 70% of billed charges IRON 83540 CPT 301 RC outpatient 19.98 13.99 Cigna Commercial PPO 10.99 percent of total billed charges 10.99 17.54 55% of Billed Charges IRON 83540 CPT 301 RC inpatient 19.98 9.99 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 9.99 16.98 Inpatient Reimbursement at 85% of Billed Charges IRON 83540 CPT 301 RC outpatient 19.98 13.99 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 10.99 17.54 Reimbursement at 85% of billed charges IRON 83540 CPT 301 RC outpatient 19.98 13.99 Aetna Commercial PPO 17.54 fee schedule 10.99 17.54 200% Of Aetna Market Fee Schedule Hospital Technical Rate LIVER FUNCTION TEST - LFT 80076 CPT 300 RC inpatient 25.23 12.62 BCBS Louisiana PPO 12.62 percent of total billed charges 12.62 21.45 50% of Eligible Charges LIVER FUNCTION TEST - LFT 80076 CPT 300 RC outpatient 25.23 17.66 BCBS Louisiana PPO 17.66 percent of total billed charges 13.88 26.72 70% of billed charges LIVER FUNCTION TEST - LFT 80076 CPT 300 RC outpatient 25.23 17.66 Cigna Commercial PPO 13.88 percent of total billed charges 13.88 26.72 55% of Billed Charges LIVER FUNCTION TEST - LFT 80076 CPT 300 RC inpatient 25.23 12.62 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 12.62 21.45 Inpatient Reimbursement at 85% of Billed Charges LIVER FUNCTION TEST - LFT 80076 CPT 300 RC outpatient 25.23 17.66 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 13.88 26.72 Reimbursement at 85% of billed charges LIVER FUNCTION TEST - LFT 80076 CPT 300 RC outpatient 25.23 17.66 Aetna Commercial PPO 26.72 fee schedule 13.88 26.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate T4 TOTAL 84436 CPT 301 RC inpatient 21.2 10.6 BCBS Louisiana PPO 10.6 percent of total billed charges 10.6 18.02 50% of Eligible Charges T4 TOTAL 84436 CPT 301 RC outpatient 21.2 14.84 BCBS Louisiana PPO 14.84 percent of total billed charges 11.66 18.02 70% of billed charges T4 TOTAL 84436 CPT 301 RC outpatient 21.2 14.84 Cigna Commercial PPO 11.66 percent of total billed charges 11.66 18.02 55% of Billed Charges T4 TOTAL 84436 CPT 301 RC inpatient 21.2 10.6 IMA of Louisiana Commercial PPO 18.02 percent of total billed charges 10.6 18.02 Inpatient Reimbursement at 85% of Billed Charges T4 TOTAL 84436 CPT 301 RC outpatient 21.2 14.84 IMA of Louisiana Commercial PPO 18.02 percent of total billed charges 11.66 18.02 Reimbursement at 85% of billed charges T4 TOTAL 84436 CPT 301 RC outpatient 21.2 14.84 Aetna Commercial PPO 15.82 fee schedule 11.66 18.02 200% Of Aetna Market Fee Schedule Hospital Technical Rate U/A WITH MICROSCOPE 81001 CPT 300 RC inpatient 9.8 4.9 BCBS Louisiana PPO 4.9 percent of total billed charges 4.9 8.33 50% of Eligible Charges U/A WITH MICROSCOPE 81001 CPT 300 RC outpatient 9.8 6.86 BCBS Louisiana PPO 6.86 percent of total billed charges 5.39 10.36 70% of billed charges U/A WITH MICROSCOPE 81001 CPT 300 RC outpatient 9.8 6.86 Cigna Commercial PPO 5.39 percent of total billed charges 5.39 10.36 55% of Billed Charges U/A WITH MICROSCOPE 81001 CPT 300 RC inpatient 9.8 4.9 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 4.9 8.33 Inpatient Reimbursement at 85% of Billed Charges U/A WITH MICROSCOPE 81001 CPT 300 RC outpatient 9.8 6.86 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 5.39 10.36 Reimbursement at 85% of billed charges U/A WITH MICROSCOPE 81001 CPT 300 RC outpatient 9.8 6.86 Aetna Commercial PPO 10.36 fee schedule 5.39 10.36 200% Of Aetna Market Fee Schedule Hospital Technical Rate FUNGAL CULTURE / MOUNT 87102 CPT 300 RC inpatient 25.95 12.98 BCBS Louisiana PPO 12.98 percent of total billed charges 12.98 22.06 50% of Eligible Charges FUNGAL CULTURE / MOUNT 87102 CPT 300 RC outpatient 25.95 18.17 BCBS Louisiana PPO 18.17 percent of total billed charges 14.27 27.48 70% of billed charges FUNGAL CULTURE / MOUNT 87102 CPT 300 RC outpatient 25.95 18.17 Cigna Commercial PPO 14.27 percent of total billed charges 14.27 27.48 55% of Billed Charges FUNGAL CULTURE / MOUNT 87102 CPT 300 RC inpatient 25.95 12.98 IMA of Louisiana Commercial PPO 22.06 percent of total billed charges 12.98 22.06 Inpatient Reimbursement at 85% of Billed Charges FUNGAL CULTURE / MOUNT 87102 CPT 300 RC outpatient 25.95 18.17 IMA of Louisiana Commercial PPO 22.06 percent of total billed charges 14.27 27.48 Reimbursement at 85% of billed charges FUNGAL CULTURE / MOUNT 87102 CPT 300 RC outpatient 25.95 18.17 Aetna Commercial PPO 27.48 fee schedule 14.27 27.48 200% Of Aetna Market Fee Schedule Hospital Technical Rate ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC inpatient 37.3 18.65 BCBS Louisiana PPO 18.65 percent of total billed charges 18.65 31.71 50% of Eligible Charges ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 BCBS Louisiana PPO 26.11 percent of total billed charges 20.52 39.52 70% of billed charges ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 Cigna Commercial PPO 20.52 percent of total billed charges 20.52 39.52 55% of Billed Charges ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC inpatient 37.3 18.65 IMA of Louisiana Commercial PPO 31.71 percent of total billed charges 18.65 31.71 Inpatient Reimbursement at 85% of Billed Charges ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 IMA of Louisiana Commercial PPO 31.71 percent of total billed charges 20.52 39.52 Reimbursement at 85% of billed charges ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 Aetna Commercial PPO 39.52 fee schedule 20.52 39.52 200% Of Aetna Market Fee Schedule Hospital Technical Rate CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC inpatient 24.93 12.47 BCBS Louisiana PPO 12.47 percent of total billed charges 12.47 21.19 50% of Eligible Charges CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC outpatient 24.93 17.45 BCBS Louisiana PPO 17.45 percent of total billed charges 13.71 26.4 70% of billed charges CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC outpatient 24.93 17.45 Cigna Commercial PPO 13.71 percent of total billed charges 13.71 26.4 55% of Billed Charges CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC inpatient 24.93 12.47 IMA of Louisiana Commercial PPO 21.19 percent of total billed charges 12.47 21.19 Inpatient Reimbursement at 85% of Billed Charges CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC outpatient 24.93 17.45 IMA of Louisiana Commercial PPO 21.19 percent of total billed charges 13.71 26.4 Reimbursement at 85% of billed charges CULTURE - ANAEROBIC ISOLATE 87076 CPT 300 RC outpatient 24.93 17.45 Aetna Commercial PPO 26.4 fee schedule 13.71 26.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC inpatient 937.68 468.84 BCBS Louisiana PPO 468.84 percent of total billed charges 468.84 797.03 50% of Eligible Charges "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC outpatient 937.68 750.14 BCBS Louisiana PPO 750.14 percent of total billed charges 515.72 1300 80% of billed charges "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC outpatient 937.68 750.14 Cigna Commercial PPO 515.72 percent of total billed charges 515.72 1300 55% of Billed Charges "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC inpatient 937.68 468.84 IMA of Louisiana Commercial PPO 797.03 percent of total billed charges 468.84 797.03 Inpatient Reimbursement at 85% of Billed Charges "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC outpatient 937.68 750.14 IMA of Louisiana Commercial PPO 797.03 percent of total billed charges 515.72 1300 Reimbursement at 85% of billed charges "TRANSFUSION,BLOOD OR BLOOD COMPONENTS" 36430 CPT 391 RC outpatient 937.68 750.14 Aetna Commercial PPO 1300 fee schedule 515.72 1300 Case Rate inpt3_BLOOD CULTURE 87040 CPT 300 RC inpatient 31.85 15.93 BCBS Louisiana PPO 15.93 percent of total billed charges 15.93 27.07 50% of Eligible Charges inpt3_BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 BCBS Louisiana PPO 22.3 percent of total billed charges 17.52 33.76 70% of billed charges inpt3_BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 Cigna Commercial PPO 17.52 percent of total billed charges 17.52 33.76 55% of Billed Charges inpt3_BLOOD CULTURE 87040 CPT 300 RC inpatient 31.85 15.93 IMA of Louisiana Commercial PPO 27.07 percent of total billed charges 15.93 27.07 Inpatient Reimbursement at 85% of Billed Charges inpt3_BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 IMA of Louisiana Commercial PPO 27.07 percent of total billed charges 17.52 33.76 Reimbursement at 85% of billed charges inpt3_BLOOD CULTURE 87040 CPT 300 RC outpatient 31.85 22.3 Aetna Commercial PPO 33.76 fee schedule 17.52 33.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR 63661 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC inpatient 262.6 131.3 BCBS Louisiana PPO 131.3 percent of total billed charges 131.3 223.21 50% of Eligible Charges REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC outpatient 262.6 210.08 BCBS Louisiana PPO 210.08 percent of total billed charges 144.43 1300 80% of billed charges REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC outpatient 262.6 210.08 Cigna Commercial PPO 144.43 percent of total billed charges 144.43 1300 55% of Billed Charges REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC inpatient 262.6 131.3 IMA of Louisiana Commercial PPO 223.21 percent of total billed charges 131.3 223.21 Inpatient Reimbursement at 85% of Billed Charges REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC outpatient 262.6 210.08 IMA of Louisiana Commercial PPO 223.21 percent of total billed charges 144.43 1300 Reimbursement at 85% of billed charges REPAIR LACERATION 2.5 CM OR LESS MOUTH 41250 CPT 360 RC outpatient 262.6 210.08 Aetna Commercial PPO 1300 fee schedule 144.43 1300 Case Rate TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 1300 11913.64 55% of Billed Charges TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges TRANSPEDICULAR APP DECOM SPINAL CORD EQU 63056 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC inpatient 9868.58 4934.29 BCBS Louisiana PPO 4934.29 percent of total billed charges 4934.29 8388.29 50% of Eligible Charges VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC outpatient 9868.58 7894.86 BCBS Louisiana PPO 7894.86 percent of total billed charges 100 8388.29 80% of billed charges VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC outpatient 9868.58 7894.86 Cigna Commercial PPO 5427.72 percent of total billed charges 100 8388.29 55% of Billed Charges VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC inpatient 9868.58 4934.29 IMA of Louisiana Commercial PPO 8388.29 percent of total billed charges 4934.29 8388.29 Inpatient Reimbursement at 85% of Billed Charges VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC outpatient 9868.58 7894.86 IMA of Louisiana Commercial PPO 8388.29 percent of total billed charges 100 8388.29 Reimbursement at 85% of billed charges VCRPEC ANT DCMPRN CRV EA SGM 63082 CPT 360 RC outpatient 9868.58 7894.86 Aetna Commercial PPO 100 fee schedule 100 8388.29 Case Rate TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC inpatient 3784.68 1892.34 BCBS Louisiana PPO 1892.34 percent of total billed charges 1892.34 3216.98 50% of Eligible Charges TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC outpatient 3784.68 3027.74 BCBS Louisiana PPO 3027.74 percent of total billed charges 1300 3216.98 80% of billed charges TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC outpatient 3784.68 3027.74 Cigna Commercial PPO 2081.57 percent of total billed charges 1300 3216.98 55% of Billed Charges TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC inpatient 3784.68 1892.34 IMA of Louisiana Commercial PPO 3216.98 percent of total billed charges 1892.34 3216.98 Inpatient Reimbursement at 85% of Billed Charges TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC outpatient 3784.68 3027.74 IMA of Louisiana Commercial PPO 3216.98 percent of total billed charges 1300 3216.98 Reimbursement at 85% of billed charges TRANSXJ/ALVSN OTH SPI NRV XDRL 64772 CPT 360 RC outpatient 3784.68 3027.74 Aetna Commercial PPO 1300 fee schedule 1300 3216.98 Case Rate DST NROLYTC ADDL IM/SA 64636 CPT 360 RC inpatient 2801.96 1400.98 BCBS Louisiana PPO 1400.98 percent of total billed charges 1400.98 2381.67 50% of Eligible Charges DST NROLYTC ADDL IM/SA 64636 CPT 360 RC outpatient 2801.96 2241.57 BCBS Louisiana PPO 2241.57 percent of total billed charges 1300 2381.67 80% of billed charges DST NROLYTC ADDL IM/SA 64636 CPT 360 RC outpatient 2801.96 2241.57 Cigna Commercial PPO 1541.08 percent of total billed charges 1300 2381.67 55% of Billed Charges DST NROLYTC ADDL IM/SA 64636 CPT 360 RC inpatient 2801.96 1400.98 IMA of Louisiana Commercial PPO 2381.67 percent of total billed charges 1400.98 2381.67 Inpatient Reimbursement at 85% of Billed Charges DST NROLYTC ADDL IM/SA 64636 CPT 360 RC outpatient 2801.96 2241.57 IMA of Louisiana Commercial PPO 2381.67 percent of total billed charges 1300 2381.67 Reimbursement at 85% of billed charges DST NROLYTC ADDL IM/SA 64636 CPT 360 RC outpatient 2801.96 2241.57 Aetna Commercial PPO 1300 fee schedule 1300 2381.67 Case Rate PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges PRQ ASPIR SPI CORD CST/SYRINX 62268 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC inpatient 1858.73 929.37 BCBS Louisiana PPO 929.37 percent of total billed charges 929.37 1579.92 50% of Eligible Charges UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC outpatient 1858.73 1486.98 BCBS Louisiana PPO 1486.98 percent of total billed charges 1022.3 1579.92 80% of billed charges UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC outpatient 1858.73 1486.98 Cigna Commercial PPO 1022.3 percent of total billed charges 1022.3 1579.92 55% of Billed Charges UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC inpatient 1858.73 929.37 IMA of Louisiana Commercial PPO 1579.92 percent of total billed charges 929.37 1579.92 Inpatient Reimbursement at 85% of Billed Charges UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC outpatient 1858.73 1486.98 IMA of Louisiana Commercial PPO 1579.92 percent of total billed charges 1022.3 1579.92 Reimbursement at 85% of billed charges UNLIS PX ADB PRTM&OMENTUM 49999 CPT 360 RC outpatient 1858.73 1486.98 Aetna Commercial PPO 1300 fee schedule 1022.3 1579.92 Case Rate EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges EXCISE INTRASPINL LESION CRV 63265 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC inpatient 5497.65 2748.83 BCBS Louisiana PPO 2748.83 percent of total billed charges 2748.83 4673 50% of Eligible Charges CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC outpatient 5497.65 4398.12 BCBS Louisiana PPO 4398.12 percent of total billed charges 100 4673 80% of billed charges CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC outpatient 5497.65 4398.12 Cigna Commercial PPO 3023.71 percent of total billed charges 100 4673 55% of Billed Charges CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC inpatient 5497.65 2748.83 IMA of Louisiana Commercial PPO 4673 percent of total billed charges 2748.83 4673 Inpatient Reimbursement at 85% of Billed Charges CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC outpatient 5497.65 4398.12 IMA of Louisiana Commercial PPO 4673 percent of total billed charges 100 4673 Reimbursement at 85% of billed charges CRANIOPLASTY SKULL DEFECT LARGER THAN 5 62141 CPT 360 RC outpatient 5497.65 4398.12 Aetna Commercial PPO 100 fee schedule 100 4673 Case Rate RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC inpatient 10662.4 5331.2 BCBS Louisiana PPO 5331.2 percent of total billed charges 5331.2 9063.04 50% of Eligible Charges RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC outpatient 10662.4 8529.92 BCBS Louisiana PPO 8529.92 percent of total billed charges 1300 9063.04 80% of billed charges RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC outpatient 10662.4 8529.92 Cigna Commercial PPO 5864.32 percent of total billed charges 1300 9063.04 55% of Billed Charges RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC inpatient 10662.4 5331.2 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 5331.2 9063.04 Inpatient Reimbursement at 85% of Billed Charges RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC outpatient 10662.4 8529.92 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 1300 9063.04 Reimbursement at 85% of billed charges RPLCMT COMPL TIN CTR VAD W/SUBW PMP 36583 CPT 360 RC outpatient 10662.4 8529.92 Aetna Commercial PPO 1300 fee schedule 1300 9063.04 Case Rate PT COMMUNITY TRAINING 97537 CPT 421 RC inpatient 83.75 41.88 BCBS Louisiana PPO 41.88 percent of total billed charges 41.88 71.19 50% of Eligible Charges PT COMMUNITY TRAINING 97537 CPT 421 RC outpatient 83.75 67 BCBS Louisiana PPO 67 percent of total billed charges 58.08 85 80% of billed charge PT COMMUNITY TRAINING 97537 CPT 421 RC outpatient 83.75 67 Cigna Commercial PPO 85 other 58.08 85 63% of Billed Charges PT COMMUNITY TRAINING 97537 CPT 421 RC inpatient 83.75 41.88 IMA of Louisiana Commercial PPO 71.19 percent of total billed charges 41.88 71.19 Inpatient Reimbursement at 85% of Billed Charges PT COMMUNITY TRAINING 97537 CPT 421 RC outpatient 83.75 67 IMA of Louisiana Commercial PPO 71.19 percent of total billed charges 58.08 85 Reimbursement at 85% of billed charges PT COMMUNITY TRAINING 97537 CPT 421 RC outpatient 83.75 67 Aetna Commercial PPO 58.08 fee schedule 58.08 85 200% Of Aetna Market Fee Schedule LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges LAM W/O OFFD 1/2 VRT SEG THRG 63003 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges NJX ANES SUPRIOR HYPOSGSTR PLEXUS 64517 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate SUTR EAC NRV HAND FOOT 64837 CPT 360 RC inpatient 9922.05 4961.03 BCBS Louisiana PPO 4961.03 percent of total billed charges 4961.03 8433.74 50% of Eligible Charges SUTR EAC NRV HAND FOOT 64837 CPT 360 RC outpatient 9922.05 7937.64 BCBS Louisiana PPO 7937.64 percent of total billed charges 1300 8433.74 80% of billed charges SUTR EAC NRV HAND FOOT 64837 CPT 360 RC outpatient 9922.05 7937.64 Cigna Commercial PPO 5457.13 percent of total billed charges 1300 8433.74 55% of Billed Charges SUTR EAC NRV HAND FOOT 64837 CPT 360 RC inpatient 9922.05 4961.03 IMA of Louisiana Commercial PPO 8433.74 percent of total billed charges 4961.03 8433.74 Inpatient Reimbursement at 85% of Billed Charges SUTR EAC NRV HAND FOOT 64837 CPT 360 RC outpatient 9922.05 7937.64 IMA of Louisiana Commercial PPO 8433.74 percent of total billed charges 1300 8433.74 Reimbursement at 85% of billed charges SUTR EAC NRV HAND FOOT 64837 CPT 360 RC outpatient 9922.05 7937.64 Aetna Commercial PPO 1300 fee schedule 1300 8433.74 Case Rate EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges EXC NEROFIBROMA/LEMMOMA MAJOR PERIPH NRV 64790 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate DSTRJ NULYT INTERC NRV 64620 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges DSTRJ NULYT INTERC NRV 64620 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges DSTRJ NULYT INTERC NRV 64620 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges DSTRJ NULYT INTERC NRV 64620 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges DSTRJ NULYT INTERC NRV 64620 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges DSTRJ NULYT INTERC NRV 64620 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC inpatient 10652.2 5326.1 BCBS Louisiana PPO 5326.1 percent of total billed charges 5326.1 9054.37 50% of Eligible Charges ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC outpatient 10652.2 8521.76 BCBS Louisiana PPO 8521.76 percent of total billed charges 1300 9054.37 80% of billed charges ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC outpatient 10652.2 8521.76 Cigna Commercial PPO 5858.71 percent of total billed charges 1300 9054.37 55% of Billed Charges ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC inpatient 10652.2 5326.1 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 5326.1 9054.37 Inpatient Reimbursement at 85% of Billed Charges ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC outpatient 10652.2 8521.76 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 1300 9054.37 Reimbursement at 85% of billed charges ARTHRS KNE DRLS OSTEO DISS GRFG 29885 CPT 360 RC outpatient 10652.2 8521.76 Aetna Commercial PPO 1300 fee schedule 1300 9054.37 Case Rate ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC inpatient 6613.08 3306.54 BCBS Louisiana PPO 3306.54 percent of total billed charges 3306.54 5621.12 50% of Eligible Charges ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC outpatient 6613.08 5290.46 BCBS Louisiana PPO 5290.46 percent of total billed charges 1300 5621.12 80% of billed charges ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC outpatient 6613.08 5290.46 Cigna Commercial PPO 3637.19 percent of total billed charges 1300 5621.12 55% of Billed Charges ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC inpatient 6613.08 3306.54 IMA of Louisiana Commercial PPO 5621.12 percent of total billed charges 3306.54 5621.12 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC outpatient 6613.08 5290.46 IMA of Louisiana Commercial PPO 5621.12 percent of total billed charges 1300 5621.12 Reimbursement at 85% of billed charges ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEM 29906 CPT 360 RC outpatient 6613.08 5290.46 Aetna Commercial PPO 1300 fee schedule 1300 5621.12 Case Rate LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 100 11913.64 6800 case rate LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges LAM BX/EXC ISPI NEO IDRL XMED THRC 63281 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate Pvb thoracic 2nd+ inj site 64462 CPT 360 RC inpatient 693.74 346.87 BCBS Louisiana PPO 346.87 percent of total billed charges 346.87 589.68 50% of Eligible Charges Pvb thoracic 2nd+ inj site 64462 CPT 360 RC outpatient 693.74 554.99 BCBS Louisiana PPO 554.99 percent of total billed charges 381.56 1300 80% of billed charges Pvb thoracic 2nd+ inj site 64462 CPT 360 RC outpatient 693.74 554.99 Cigna Commercial PPO 381.56 percent of total billed charges 381.56 1300 55% of Billed Charges Pvb thoracic 2nd+ inj site 64462 CPT 360 RC inpatient 693.74 346.87 IMA of Louisiana Commercial PPO 589.68 percent of total billed charges 346.87 589.68 Inpatient Reimbursement at 85% of Billed Charges Pvb thoracic 2nd+ inj site 64462 CPT 360 RC outpatient 693.74 554.99 IMA of Louisiana Commercial PPO 589.68 percent of total billed charges 381.56 1300 Reimbursement at 85% of billed charges Pvb thoracic 2nd+ inj site 64462 CPT 360 RC outpatient 693.74 554.99 Aetna Commercial PPO 1300 fee schedule 381.56 1300 Case Rate LIG MAJOR ART XTR 37618 CPT 360 RC inpatient 9384.13 4692.07 BCBS Louisiana PPO 4692.07 percent of total billed charges 4692.07 7976.51 50% of Eligible Charges LIG MAJOR ART XTR 37618 CPT 360 RC outpatient 9384.13 7507.3 BCBS Louisiana PPO 7507.3 percent of total billed charges 100 7976.51 80% of billed charges LIG MAJOR ART XTR 37618 CPT 360 RC outpatient 9384.13 7507.3 Cigna Commercial PPO 5161.27 percent of total billed charges 100 7976.51 55% of Billed Charges LIG MAJOR ART XTR 37618 CPT 360 RC inpatient 9384.13 4692.07 IMA of Louisiana Commercial PPO 7976.51 percent of total billed charges 4692.07 7976.51 Inpatient Reimbursement at 85% of Billed Charges LIG MAJOR ART XTR 37618 CPT 360 RC outpatient 9384.13 7507.3 IMA of Louisiana Commercial PPO 7976.51 percent of total billed charges 100 7976.51 Reimbursement at 85% of billed charges LIG MAJOR ART XTR 37618 CPT 360 RC outpatient 9384.13 7507.3 Aetna Commercial PPO 100 fee schedule 100 7976.51 Case Rate XRAY DX RT TOES 73660 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT TOES 73660 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT TOES 73660 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT TOES 73660 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT TOES 73660 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT TOES 73660 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT LEFT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges CT OF ABDOMEN W/ CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition PT MANUAL THERAPY 97140 CPT 421 RC inpatient 27.83 13.92 BCBS Louisiana PPO 13.92 percent of total billed charges 13.92 23.66 50% of Eligible Charges PT MANUAL THERAPY 97140 CPT 421 RC outpatient 27.83 22.26 BCBS Louisiana PPO 22.26 percent of total billed charges 22.26 85 80% of billed charge PT MANUAL THERAPY 97140 CPT 421 RC outpatient 27.83 22.26 Cigna Commercial PPO 85 other 22.26 85 63% of Billed Charges PT MANUAL THERAPY 97140 CPT 421 RC inpatient 27.83 13.92 IMA of Louisiana Commercial PPO 23.66 percent of total billed charges 13.92 23.66 Inpatient Reimbursement at 85% of Billed Charges PT MANUAL THERAPY 97140 CPT 421 RC outpatient 27.83 22.26 IMA of Louisiana Commercial PPO 23.66 percent of total billed charges 22.26 85 Reimbursement at 85% of billed charges PT MANUAL THERAPY 97140 CPT 421 RC outpatient 27.83 22.26 Aetna Commercial PPO 57.06 fee schedule 22.26 85 200% Of Aetna Market Fee Schedule PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC inpatient 30.85 15.43 BCBS Louisiana PPO 15.43 percent of total billed charges 15.43 26.22 50% of Eligible Charges PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC outpatient 30.85 24.68 BCBS Louisiana PPO 24.68 percent of total billed charges 24.68 85 80% of billed charge PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC outpatient 30.85 24.68 Cigna Commercial PPO 85 other 24.68 85 63% of Billed Charges PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC inpatient 30.85 15.43 IMA of Louisiana Commercial PPO 26.22 percent of total billed charges 15.43 26.22 Inpatient Reimbursement at 85% of Billed Charges PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC outpatient 30.85 24.68 IMA of Louisiana Commercial PPO 26.22 percent of total billed charges 24.68 85 Reimbursement at 85% of billed charges PT NEUROMUSCULAR REEDUCATION OF MOVEMENT 97112 CPT 421 RC outpatient 30.85 24.68 Aetna Commercial PPO 64.44 fee schedule 24.68 85 200% Of Aetna Market Fee Schedule PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC inpatient 44.45 22.23 BCBS Louisiana PPO 22.23 percent of total billed charges 22.23 37.78 50% of Eligible Charges PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC outpatient 44.45 35.56 BCBS Louisiana PPO 35.56 percent of total billed charges 24.8 85 80% of billed charge PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC outpatient 44.45 35.56 Cigna Commercial PPO 85 other 24.8 85 63% of Billed Charges PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC inpatient 44.45 22.23 IMA of Louisiana Commercial PPO 37.78 percent of total billed charges 22.23 37.78 Inpatient Reimbursement at 85% of Billed Charges PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC outpatient 44.45 35.56 IMA of Louisiana Commercial PPO 37.78 percent of total billed charges 24.8 85 Reimbursement at 85% of billed charges PT ULTRASOUND EA 15 MINUTES 97035 CPT 421 RC outpatient 44.45 35.56 Aetna Commercial PPO 24.8 fee schedule 24.8 85 200% Of Aetna Market Fee Schedule PT WHIRLPOOL 97022 CPT 421 RC inpatient 15.22 7.61 BCBS Louisiana PPO 7.61 percent of total billed charges 7.61 12.94 50% of Eligible Charges PT WHIRLPOOL 97022 CPT 421 RC outpatient 15.22 12.18 BCBS Louisiana PPO 12.18 percent of total billed charges 12.18 85 80% of billed charge PT WHIRLPOOL 97022 CPT 421 RC outpatient 15.22 12.18 Cigna Commercial PPO 85 other 12.18 85 63% of Billed Charges PT WHIRLPOOL 97022 CPT 421 RC inpatient 15.22 7.61 IMA of Louisiana Commercial PPO 12.94 percent of total billed charges 7.61 12.94 Inpatient Reimbursement at 85% of Billed Charges PT WHIRLPOOL 97022 CPT 421 RC outpatient 15.22 12.18 IMA of Louisiana Commercial PPO 12.94 percent of total billed charges 12.18 85 Reimbursement at 85% of billed charges PT WHIRLPOOL 97022 CPT 421 RC outpatient 15.22 12.18 Aetna Commercial PPO 43.52 fee schedule 12.18 85 200% Of Aetna Market Fee Schedule inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC inpatient 41.8 20.9 BCBS Louisiana PPO 20.9 percent of total billed charges 20.9 35.53 50% of Eligible Charges inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 BCBS Louisiana PPO 29.26 percent of total billed charges 22.99 44.3 70% of billed charges inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 Cigna Commercial PPO 22.99 percent of total billed charges 22.99 44.3 55% of Billed Charges inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC inpatient 41.8 20.9 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 20.9 35.53 Inpatient Reimbursement at 85% of Billed Charges inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 22.99 44.3 Reimbursement at 85% of billed charges inpt3_VANCOMYCIN TROUGH 80202 CPT 300 RC outpatient 41.8 29.26 Aetna Commercial PPO 44.3 fee schedule 22.99 44.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_LDH LEVEL 83615 CPT 300 RC inpatient 18.63 9.32 BCBS Louisiana PPO 9.32 percent of total billed charges 9.32 15.84 50% of Eligible Charges inpt3_LDH LEVEL 83615 CPT 300 RC outpatient 18.63 13.04 BCBS Louisiana PPO 13.04 percent of total billed charges 10.25 19.72 70% of billed charges inpt3_LDH LEVEL 83615 CPT 300 RC outpatient 18.63 13.04 Cigna Commercial PPO 10.25 percent of total billed charges 10.25 19.72 55% of Billed Charges inpt3_LDH LEVEL 83615 CPT 300 RC inpatient 18.63 9.32 IMA of Louisiana Commercial PPO 15.84 percent of total billed charges 9.32 15.84 Inpatient Reimbursement at 85% of Billed Charges inpt3_LDH LEVEL 83615 CPT 300 RC outpatient 18.63 13.04 IMA of Louisiana Commercial PPO 15.84 percent of total billed charges 10.25 19.72 Reimbursement at 85% of billed charges inpt3_LDH LEVEL 83615 CPT 300 RC outpatient 18.63 13.04 Aetna Commercial PPO 19.72 fee schedule 10.25 19.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_LIVER FUNCTION 80076 CPT 300 RC inpatient 25.23 12.62 BCBS Louisiana PPO 12.62 percent of total billed charges 12.62 21.45 50% of Eligible Charges inpt3_LIVER FUNCTION 80076 CPT 300 RC outpatient 25.23 17.66 BCBS Louisiana PPO 17.66 percent of total billed charges 13.88 26.72 70% of billed charges inpt3_LIVER FUNCTION 80076 CPT 300 RC outpatient 25.23 17.66 Cigna Commercial PPO 13.88 percent of total billed charges 13.88 26.72 55% of Billed Charges inpt3_LIVER FUNCTION 80076 CPT 300 RC inpatient 25.23 12.62 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 12.62 21.45 Inpatient Reimbursement at 85% of Billed Charges inpt3_LIVER FUNCTION 80076 CPT 300 RC outpatient 25.23 17.66 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 13.88 26.72 Reimbursement at 85% of billed charges inpt3_LIVER FUNCTION 80076 CPT 300 RC outpatient 25.23 17.66 Aetna Commercial PPO 26.72 fee schedule 13.88 26.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate STORAGE FEE - PLATELETS P9034 HCPCS 390 RC inpatient 898.13 449.07 BCBS Louisiana PPO 449.07 percent of total billed charges 449.07 763.41 50% of Eligible Charges STORAGE FEE - PLATELETS P9034 HCPCS 390 RC outpatient 898.13 718.5 BCBS Louisiana PPO 718.5 percent of total billed charges 493.97 763.41 80% of billed charge STORAGE FEE - PLATELETS P9034 HCPCS 390 RC outpatient 898.13 718.5 Cigna Commercial PPO 493.97 percent of total billed charges 493.97 763.41 55% of Billed Charges STORAGE FEE - PLATELETS P9034 HCPCS 390 RC inpatient 898.13 449.07 IMA of Louisiana Commercial PPO 763.41 percent of total billed charges 449.07 763.41 Inpatient Reimbursement at 85% of Billed Charges STORAGE FEE - PLATELETS P9034 HCPCS 390 RC outpatient 898.13 718.5 IMA of Louisiana Commercial PPO 763.41 percent of total billed charges 493.97 763.41 Reimbursement at 85% of billed charges STORAGE FEE - PLATELETS P9034 HCPCS 390 RC outpatient 898.13 718.5 Aetna Commercial PPO 493.97 percent of total billed charges 493.97 763.41 55 of billed Charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC inpatient 44.98 22.49 BCBS Louisiana PPO 22.49 percent of total billed charges 22.49 38.23 50% of Eligible Charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 BCBS Louisiana PPO 31.49 percent of total billed charges 24.74 47.64 70% of billed charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 Cigna Commercial PPO 24.74 percent of total billed charges 24.74 47.64 55% of Billed Charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC inpatient 44.98 22.49 IMA of Louisiana Commercial PPO 38.23 percent of total billed charges 22.49 38.23 Inpatient Reimbursement at 85% of Billed Charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 IMA of Louisiana Commercial PPO 38.23 percent of total billed charges 24.74 47.64 Reimbursement at 85% of billed charges inpt3_ AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 Aetna Commercial PPO 47.64 fee schedule 24.74 47.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC inpatient 39.95 19.98 BCBS Louisiana PPO 19.98 percent of total billed charges 19.98 33.96 50% of Eligible Charges CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC outpatient 39.95 27.97 BCBS Louisiana PPO 27.97 percent of total billed charges 21.97 42.32 70% of billed charges CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC outpatient 39.95 27.97 Cigna Commercial PPO 21.97 percent of total billed charges 21.97 42.32 55% of Billed Charges CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC inpatient 39.95 19.98 IMA of Louisiana Commercial PPO 33.96 percent of total billed charges 19.98 33.96 Inpatient Reimbursement at 85% of Billed Charges CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC outpatient 39.95 27.97 IMA of Louisiana Commercial PPO 33.96 percent of total billed charges 21.97 42.32 Reimbursement at 85% of billed charges CYCLIC CITRULLINATED PEPTID AB 86200 CPT 302 RC outpatient 39.95 27.97 Aetna Commercial PPO 42.32 fee schedule 21.97 42.32 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX ABDOMEN AP 74018 CPT 320 RC inpatient 235 117.5 BCBS Louisiana PPO 117.5 percent of total billed charges 117.5 199.75 50% of Eligible Charges XRAY DX ABDOMEN AP 74018 CPT 320 RC outpatient 235 164.5 BCBS Louisiana PPO 164.5 percent of total billed charges 129.25 700 70% of billed charges XRAY DX ABDOMEN AP 74018 CPT 320 RC outpatient 235 164.5 Cigna Commercial PPO 129.25 percent of total billed charges 129.25 700 55% of Billed Charges XRAY DX ABDOMEN AP 74018 CPT 320 RC inpatient 235 117.5 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 117.5 199.75 Inpatient Reimbursement at 85% of Billed Charges XRAY DX ABDOMEN AP 74018 CPT 320 RC outpatient 235 164.5 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 129.25 700 Reimbursement at 85% of billed charges XRAY DX ABDOMEN AP 74018 CPT 320 RC outpatient 235 164.5 Aetna Commercial PPO 700 case rate 129.25 700 700 Per Code Per DOS Paid In Addition XRAY DX CLAVICLE 73000 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX CLAVICLE 73000 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX CLAVICLE 73000 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX CLAVICLE 73000 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX CLAVICLE 73000 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX CLAVICLE 73000 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT FEMUR 73552 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT FEMUR 73552 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT FEMUR 73552 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT FEMUR 73552 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT FEMUR 73552 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT FEMUR 73552 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT FINGERS 73140 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT FINGERS 73140 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT FINGERS 73140 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT FINGERS 73140 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT FINGERS 73140 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT FINGERS 73140 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT KNEE 2 VIEWS 73560 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT SHOULDER 73020 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT SHOULDER 73020 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT SHOULDER 73020 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT SHOULDER 73020 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT SHOULDER 73020 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT SHOULDER 73020 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX SPINE SINGLE VI 72020 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX SPINE SINGLE VI 72020 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX SPINE SINGLE VI 72020 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX SPINE SINGLE VI 72020 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX SPINE SINGLE VI 72020 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX SPINE SINGLE VI 72020 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX SPINETHORACIC A 72070 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX SPINETHORACIC A 72070 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX SPINETHORACIC A 72070 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX SPINETHORACIC A 72070 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX SPINETHORACIC A 72070 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX SPINETHORACIC A 72070 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT TIBIA & FIBULA 73590 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT ANKLE COMPLETE 73610 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT ELBOW AP&LAT 73070 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT TIBIA & FIBULA 73590 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI LOWER JOINT EXTREMITY 73721 CPT 619 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 BCBS Louisiana PPO 2818.38 percent of total billed charges 700 3422.31 70% of billed charges C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Cigna Commercial PPO 2214.44 percent of total billed charges 700 3422.31 55% of Billed Charges C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 700 3422.31 Reimbursement at 85% of billed charges C-ARM DISCOGRAM 4TH LEVEL 72295 CPT 320 RC 59 outpatient 4026.25 2818.38 Aetna Commercial PPO 700 case rate 700 3422.31 700 Per Code Per DOS Paid In Addition CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC inpatient 1140.93 570.47 BCBS Louisiana PPO 570.47 percent of total billed charges 570.47 969.79 50% of Eligible Charges CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC outpatient 1140.93 798.65 BCBS Louisiana PPO 798.65 percent of total billed charges 627.51 969.79 70% of billed charges CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC outpatient 1140.93 798.65 Cigna Commercial PPO 627.51 percent of total billed charges 627.51 969.79 55% of Billed Charges CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC inpatient 1140.93 570.47 IMA of Louisiana Commercial PPO 969.79 percent of total billed charges 570.47 969.79 Inpatient Reimbursement at 85% of Billed Charges CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC outpatient 1140.93 798.65 IMA of Louisiana Commercial PPO 969.79 percent of total billed charges 627.51 969.79 Reimbursement at 85% of billed charges CT LUMBAR SPINE WITH DYE 72132 CPT 320 RC outpatient 1140.93 798.65 Aetna Commercial PPO 700 case rate 627.51 969.79 700 Per Code Per DOS Paid In Addition CT ABD & PELV W CONTRAST 74177 CPT 320 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT ABD & PELV W CONTRAST 74177 CPT 320 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 347.52 700 70% of billed charges CT ABD & PELV W CONTRAST 74177 CPT 320 RC outpatient 631.85 442.3 Cigna Commercial PPO 347.52 percent of total billed charges 347.52 700 55% of Billed Charges CT ABD & PELV W CONTRAST 74177 CPT 320 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT ABD & PELV W CONTRAST 74177 CPT 320 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 347.52 700 Reimbursement at 85% of billed charges CT ABD & PELV W CONTRAST 74177 CPT 320 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 347.52 700 700 Per Code Per DOS Paid In Addition GELFOAM SPONGE 100 250 RC 0009034201 NDC inpatient 1 EA 364.92 182.46 BCBS Louisiana PPO 182.46 percent of total billed charges 182.46 310.18 50% of Eligible Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 BCBS Louisiana PPO 291.94 percent of total billed charges 200.71 310.18 80% of billed charge GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 Cigna Commercial PPO 200.71 percent of total billed charges 200.71 310.18 55% of Billed Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC inpatient 1 EA 364.92 182.46 IMA of Louisiana Commercial PPO 310.18 percent of total billed charges 182.46 310.18 Inpatient Reimbursement at 85% of Billed Charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 IMA of Louisiana Commercial PPO 310.18 percent of total billed charges 200.71 310.18 Reimbursement at 85% of billed charges GELFOAM SPONGE 100 250 RC 0009034201 NDC outpatient 1 EA 364.92 291.94 Aetna Commercial PPO 200.71 percent of total billed charges 200.71 310.18 55 of billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC inpatient 1 EA 26.2 13.1 BCBS Louisiana PPO 13.1 percent of total billed charges 13.1 22.27 50% of Eligible Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 BCBS Louisiana PPO 20.96 percent of total billed charges 14.41 22.27 80% of billed charge PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 Cigna Commercial PPO 14.41 percent of total billed charges 14.41 22.27 55% of Billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC inpatient 1 EA 26.2 13.1 IMA of Louisiana Commercial PPO 22.27 percent of total billed charges 13.1 22.27 Inpatient Reimbursement at 85% of Billed Charges PHENOL 89% EZ SWAB J3490 HCPCS 250 RC 0884629730 NDC outpatient 1 EA 26.2 20.96 IMA of Louisiana Commercial PPO 22.27 percent of total billed charges 14.41 22.27 Reimbursement at 85% of billed charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC inpatient 1 EA 9.45 4.73 BCBS Louisiana PPO 4.73 percent of total billed charges 4.73 8.03 50% of Eligible Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 BCBS Louisiana PPO 7.56 percent of total billed charges 5.2 8.03 80% of billed charge MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 Cigna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55% of Billed Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC inpatient 1 EA 9.45 4.73 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 4.73 8.03 Inpatient Reimbursement at 85% of Billed Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 5.2 8.03 Reimbursement at 85% of billed charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 Aetna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55 of billed Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC inpatient 1 EA 3.82 1.91 BCBS Louisiana PPO 1.91 percent of total billed charges 1.91 3.25 50% of Eligible Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 BCBS Louisiana PPO 3.06 percent of total billed charges 2.1 3.25 80% of billed charge CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 Cigna Commercial PPO 2.1 percent of total billed charges 2.1 3.25 55% of Billed Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC inpatient 1 EA 3.82 1.91 IMA of Louisiana Commercial PPO 3.25 percent of total billed charges 1.91 3.25 Inpatient Reimbursement at 85% of Billed Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 IMA of Louisiana Commercial PPO 3.25 percent of total billed charges 2.1 3.25 Reimbursement at 85% of billed charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 Aetna Commercial PPO 2.1 percent of total billed charges 2.1 3.25 55 of billed Charges DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DOCUSATE SODIUM 100MG GELCAP 250 RC 0904718361 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges EPINEPHRINE 1:10000 SYRG : 10ML J0171 HCPCS 260 RC 7632933181 NDC inpatient 10 ML 68.82 34.41 BCBS Louisiana PPO 34.41 percent of total billed charges 34.41 58.5 50% of Eligible Charges EPINEPHRINE 1:10000 SYRG : 10ML J0171 HCPCS 260 RC 7632933181 NDC outpatient 10 ML 68.82 55.06 BCBS Louisiana PPO 55.06 percent of total billed charges 37.85 58.5 80% of billed charge EPINEPHRINE 1:10000 SYRG : 10ML J0171 HCPCS 260 RC 7632933181 NDC outpatient 10 ML 68.82 55.06 Cigna Commercial PPO 37.85 percent of total billed charges 37.85 58.5 55% of Billed Charges EPINEPHRINE 1:10000 SYRG : 10ML J0171 HCPCS 260 RC 7632933181 NDC inpatient 10 ML 68.82 34.41 IMA of Louisiana Commercial PPO 58.5 percent of total billed charges 34.41 58.5 Inpatient Reimbursement at 85% of Billed Charges EPINEPHRINE 1:10000 SYRG : 10ML J0171 HCPCS 260 RC 7632933181 NDC outpatient 10 ML 68.82 55.06 IMA of Louisiana Commercial PPO 58.5 percent of total billed charges 37.85 58.5 Reimbursement at 85% of billed charges EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC inpatient 1 ML 45.6 22.8 BCBS Louisiana PPO 22.8 percent of total billed charges 22.8 38.76 50% of Eligible Charges EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC outpatient 1 ML 45.6 36.48 BCBS Louisiana PPO 36.48 percent of total billed charges 25.08 38.76 80% of billed charge EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC outpatient 1 ML 45.6 36.48 Cigna Commercial PPO 25.08 percent of total billed charges 25.08 38.76 55% of Billed Charges EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC inpatient 1 ML 45.6 22.8 IMA of Louisiana Commercial PPO 38.76 percent of total billed charges 22.8 38.76 Inpatient Reimbursement at 85% of Billed Charges EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC outpatient 1 ML 45.6 36.48 IMA of Louisiana Commercial PPO 38.76 percent of total billed charges 25.08 38.76 Reimbursement at 85% of billed charges EPINEPHRINE 1:1000 INJ : 1ML 260 RC 5428810310 NDC outpatient 1 ML 45.6 36.48 Aetna Commercial PPO 25.08 percent of total billed charges 25.08 38.76 55 of billed Charges LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC inpatient 5 ME 10.02 5.01 BCBS Louisiana PPO 5.01 percent of total billed charges 5.01 8.52 50% of Eligible Charges LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC outpatient 5 ME 10.02 8.02 BCBS Louisiana PPO 8.02 percent of total billed charges 5.51 8.52 80% of billed charge LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC outpatient 5 ME 10.02 8.02 Cigna Commercial PPO 5.51 percent of total billed charges 5.51 8.52 55% of Billed Charges LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC inpatient 5 ME 10.02 5.01 IMA of Louisiana Commercial PPO 8.52 percent of total billed charges 5.01 8.52 Inpatient Reimbursement at 85% of Billed Charges LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC outpatient 5 ME 10.02 8.02 IMA of Louisiana Commercial PPO 8.52 percent of total billed charges 5.51 8.52 Reimbursement at 85% of billed charges LABETALOL 5MG/ML 20ML 260 RC 0143962201 NDC outpatient 5 ME 10.02 8.02 Aetna Commercial PPO 5.51 percent of total billed charges 5.51 8.52 55 of billed Charges FUROSEMIDE 10MG/ML 4ML J1940 HCPCS 250 RC 3600028325 NDC inpatient 10 ME 5.46 2.73 BCBS Louisiana PPO 2.73 percent of total billed charges 2.73 4.64 50% of Eligible Charges FUROSEMIDE 10MG/ML 4ML J1940 HCPCS 250 RC 3600028325 NDC outpatient 10 ME 5.46 4.37 BCBS Louisiana PPO 4.37 percent of total billed charges 3 4.64 80% of billed charge FUROSEMIDE 10MG/ML 4ML J1940 HCPCS 250 RC 3600028325 NDC outpatient 10 ME 5.46 4.37 Cigna Commercial PPO 3 percent of total billed charges 3 4.64 55% of Billed Charges FUROSEMIDE 10MG/ML 4ML J1940 HCPCS 250 RC 3600028325 NDC inpatient 10 ME 5.46 2.73 IMA of Louisiana Commercial PPO 4.64 percent of total billed charges 2.73 4.64 Inpatient Reimbursement at 85% of Billed Charges FUROSEMIDE 10MG/ML 4ML J1940 HCPCS 250 RC 3600028325 NDC outpatient 10 ME 5.46 4.37 IMA of Louisiana Commercial PPO 4.64 percent of total billed charges 3 4.64 Reimbursement at 85% of billed charges BUPIVACAINE 0.25% 10ML J3490 HCPCS 250 RC 5515016710 NDC inpatient 10 ML 6.84 3.42 BCBS Louisiana PPO 3.42 percent of total billed charges 3.42 5.81 50% of Eligible Charges BUPIVACAINE 0.25% 10ML J3490 HCPCS 250 RC 5515016710 NDC outpatient 10 ML 6.84 5.47 BCBS Louisiana PPO 5.47 percent of total billed charges 3.76 5.81 80% of billed charge BUPIVACAINE 0.25% 10ML J3490 HCPCS 250 RC 5515016710 NDC outpatient 10 ML 6.84 5.47 Cigna Commercial PPO 3.76 percent of total billed charges 3.76 5.81 55% of Billed Charges BUPIVACAINE 0.25% 10ML J3490 HCPCS 250 RC 5515016710 NDC inpatient 10 ML 6.84 3.42 IMA of Louisiana Commercial PPO 5.81 percent of total billed charges 3.42 5.81 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.25% 10ML J3490 HCPCS 250 RC 5515016710 NDC outpatient 10 ML 6.84 5.47 IMA of Louisiana Commercial PPO 5.81 percent of total billed charges 3.76 5.81 Reimbursement at 85% of billed charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges NALOXONE 0.4MG 1ML J2310 HCPCS 250 RC 0641613225 NDC inpatient 0.4 ME 19.54 9.77 BCBS Louisiana PPO 9.77 percent of total billed charges 9.77 16.61 50% of Eligible Charges NALOXONE 0.4MG 1ML J2310 HCPCS 250 RC 0641613225 NDC outpatient 0.4 ME 19.54 15.63 BCBS Louisiana PPO 15.63 percent of total billed charges 10.75 16.61 80% of billed charge NALOXONE 0.4MG 1ML J2310 HCPCS 250 RC 0641613225 NDC outpatient 0.4 ME 19.54 15.63 Cigna Commercial PPO 10.75 percent of total billed charges 10.75 16.61 55% of Billed Charges NALOXONE 0.4MG 1ML J2310 HCPCS 250 RC 0641613225 NDC inpatient 0.4 ME 19.54 9.77 IMA of Louisiana Commercial PPO 16.61 percent of total billed charges 9.77 16.61 Inpatient Reimbursement at 85% of Billed Charges NALOXONE 0.4MG 1ML J2310 HCPCS 250 RC 0641613225 NDC outpatient 0.4 ME 19.54 15.63 IMA of Louisiana Commercial PPO 16.61 percent of total billed charges 10.75 16.61 Reimbursement at 85% of billed charges NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC inpatient 1 ML 61.68 30.84 BCBS Louisiana PPO 30.84 percent of total billed charges 30.84 52.43 50% of Eligible Charges NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC outpatient 1 ML 61.68 49.34 BCBS Louisiana PPO 49.34 percent of total billed charges 33.92 52.43 80% of billed charge NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC outpatient 1 ML 61.68 49.34 Cigna Commercial PPO 33.92 percent of total billed charges 33.92 52.43 55% of Billed Charges NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC inpatient 1 ML 61.68 30.84 IMA of Louisiana Commercial PPO 52.43 percent of total billed charges 30.84 52.43 Inpatient Reimbursement at 85% of Billed Charges NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC outpatient 1 ML 61.68 49.34 IMA of Louisiana Commercial PPO 52.43 percent of total billed charges 33.92 52.43 Reimbursement at 85% of billed charges NEOSPORIN GU IRRIGANT 1ML 250 RC 3982212015 NDC outpatient 1 ML 61.68 49.34 Aetna Commercial PPO 33.92 percent of total billed charges 33.92 52.43 55 of billed Charges CLINDAMYCIN 600MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338361224 NDC inpatient 600 ME 44.05 22.03 BCBS Louisiana PPO 22.03 percent of total billed charges 22.03 37.44 50% of Eligible Charges CLINDAMYCIN 600MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338361224 NDC outpatient 600 ME 44.05 35.24 BCBS Louisiana PPO 35.24 percent of total billed charges 24.23 37.44 80% of billed charge CLINDAMYCIN 600MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338361224 NDC outpatient 600 ME 44.05 35.24 Cigna Commercial PPO 24.23 percent of total billed charges 24.23 37.44 55% of Billed Charges CLINDAMYCIN 600MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338361224 NDC inpatient 600 ME 44.05 22.03 IMA of Louisiana Commercial PPO 37.44 percent of total billed charges 22.03 37.44 Inpatient Reimbursement at 85% of Billed Charges CLINDAMYCIN 600MG/D5W 50ML IVPB J3490 HCPCS 260 RC 0338361224 NDC outpatient 600 ME 44.05 35.24 IMA of Louisiana Commercial PPO 37.44 percent of total billed charges 24.23 37.44 Reimbursement at 85% of billed charges NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC inpatient 0.4 ME 21.5 10.75 BCBS Louisiana PPO 10.75 percent of total billed charges 10.75 18.28 50% of Eligible Charges NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC outpatient 0.4 ME 21.5 17.2 BCBS Louisiana PPO 17.2 percent of total billed charges 11.83 18.28 80% of billed charge NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC outpatient 0.4 ME 21.5 17.2 Cigna Commercial PPO 11.83 percent of total billed charges 11.83 18.28 55% of Billed Charges NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC inpatient 0.4 ME 21.5 10.75 IMA of Louisiana Commercial PPO 18.28 percent of total billed charges 10.75 18.28 Inpatient Reimbursement at 85% of Billed Charges NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC outpatient 0.4 ME 21.5 17.2 IMA of Louisiana Commercial PPO 18.28 percent of total billed charges 11.83 18.28 Reimbursement at 85% of billed charges NITROGLYCERIN SL 0.4MG TABLET 250 RC 4359843611 NDC outpatient 0.4 ME 21.5 17.2 Aetna Commercial PPO 11.83 percent of total billed charges 11.83 18.28 55 of billed Charges SILVER SULFADIAZINE CREAM 25GM J3490 HCPCS 250 RC 6787712425 NDC inpatient 25 GR 66.9 33.45 BCBS Louisiana PPO 33.45 percent of total billed charges 33.45 56.87 50% of Eligible Charges SILVER SULFADIAZINE CREAM 25GM J3490 HCPCS 250 RC 6787712425 NDC outpatient 25 GR 66.9 53.52 BCBS Louisiana PPO 53.52 percent of total billed charges 36.8 56.87 80% of billed charge SILVER SULFADIAZINE CREAM 25GM J3490 HCPCS 250 RC 6787712425 NDC outpatient 25 GR 66.9 53.52 Cigna Commercial PPO 36.8 percent of total billed charges 36.8 56.87 55% of Billed Charges SILVER SULFADIAZINE CREAM 25GM J3490 HCPCS 250 RC 6787712425 NDC inpatient 25 GR 66.9 33.45 IMA of Louisiana Commercial PPO 56.87 percent of total billed charges 33.45 56.87 Inpatient Reimbursement at 85% of Billed Charges SILVER SULFADIAZINE CREAM 25GM J3490 HCPCS 250 RC 6787712425 NDC outpatient 25 GR 66.9 53.52 IMA of Louisiana Commercial PPO 56.87 percent of total billed charges 36.8 56.87 Reimbursement at 85% of billed charges VANCOMYCIN 1GM VIAL J3370 HCPCS 250 RC 6332328426 NDC inpatient 1 GR 12.12 6.06 BCBS Louisiana PPO 6.06 percent of total billed charges 6.06 10.3 50% of Eligible Charges VANCOMYCIN 1GM VIAL J3370 HCPCS 250 RC 6332328426 NDC outpatient 1 GR 12.12 9.7 BCBS Louisiana PPO 9.7 percent of total billed charges 6.67 10.3 80% of billed charge VANCOMYCIN 1GM VIAL J3370 HCPCS 250 RC 6332328426 NDC outpatient 1 GR 12.12 9.7 Cigna Commercial PPO 6.67 percent of total billed charges 6.67 10.3 55% of Billed Charges VANCOMYCIN 1GM VIAL J3370 HCPCS 250 RC 6332328426 NDC inpatient 1 GR 12.12 6.06 IMA of Louisiana Commercial PPO 10.3 percent of total billed charges 6.06 10.3 Inpatient Reimbursement at 85% of Billed Charges VANCOMYCIN 1GM VIAL J3370 HCPCS 250 RC 6332328426 NDC outpatient 1 GR 12.12 9.7 IMA of Louisiana Commercial PPO 10.3 percent of total billed charges 6.67 10.3 Reimbursement at 85% of billed charges MIDAZOLAM 1MG/ML 2ML J2250 HCPCS 250 RC 0409230517 NDC inpatient 2 ME 3.66 1.83 BCBS Louisiana PPO 1.83 percent of total billed charges 1.83 3.11 50% of Eligible Charges MIDAZOLAM 1MG/ML 2ML J2250 HCPCS 250 RC 0409230517 NDC outpatient 2 ME 3.66 2.93 BCBS Louisiana PPO 2.93 percent of total billed charges 2.01 3.11 80% of billed charge MIDAZOLAM 1MG/ML 2ML J2250 HCPCS 250 RC 0409230517 NDC outpatient 2 ME 3.66 2.93 Cigna Commercial PPO 2.01 percent of total billed charges 2.01 3.11 55% of Billed Charges MIDAZOLAM 1MG/ML 2ML J2250 HCPCS 250 RC 0409230517 NDC inpatient 2 ME 3.66 1.83 IMA of Louisiana Commercial PPO 3.11 percent of total billed charges 1.83 3.11 Inpatient Reimbursement at 85% of Billed Charges MIDAZOLAM 1MG/ML 2ML J2250 HCPCS 250 RC 0409230517 NDC outpatient 2 ME 3.66 2.93 IMA of Louisiana Commercial PPO 3.11 percent of total billed charges 2.01 3.11 Reimbursement at 85% of billed charges HYDROXYZINE 50MG/ML 1ML J3410 HCPCS 250 RC 0517560125 NDC inpatient 25 ME 135.93 67.97 BCBS Louisiana PPO 67.97 percent of total billed charges 67.97 115.54 50% of Eligible Charges HYDROXYZINE 50MG/ML 1ML J3410 HCPCS 250 RC 0517560125 NDC outpatient 25 ME 135.93 108.74 BCBS Louisiana PPO 108.74 percent of total billed charges 74.76 115.54 80% of billed charge HYDROXYZINE 50MG/ML 1ML J3410 HCPCS 250 RC 0517560125 NDC outpatient 25 ME 135.93 108.74 Cigna Commercial PPO 74.76 percent of total billed charges 74.76 115.54 55% of Billed Charges HYDROXYZINE 50MG/ML 1ML J3410 HCPCS 250 RC 0517560125 NDC inpatient 25 ME 135.93 67.97 IMA of Louisiana Commercial PPO 115.54 percent of total billed charges 67.97 115.54 Inpatient Reimbursement at 85% of Billed Charges HYDROXYZINE 50MG/ML 1ML J3410 HCPCS 250 RC 0517560125 NDC outpatient 25 ME 135.93 108.74 IMA of Louisiana Commercial PPO 115.54 percent of total billed charges 74.76 115.54 Reimbursement at 85% of billed charges HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC inpatient 7.5 ME 21.3 10.65 BCBS Louisiana PPO 10.65 percent of total billed charges 10.65 18.11 50% of Eligible Charges HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC outpatient 7.5 ME 21.3 17.04 BCBS Louisiana PPO 17.04 percent of total billed charges 11.72 18.11 80% of billed charge HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC outpatient 7.5 ME 21.3 17.04 Cigna Commercial PPO 11.72 percent of total billed charges 11.72 18.11 55% of Billed Charges HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC inpatient 7.5 ME 21.3 10.65 IMA of Louisiana Commercial PPO 18.11 percent of total billed charges 10.65 18.11 Inpatient Reimbursement at 85% of Billed Charges HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC outpatient 7.5 ME 21.3 17.04 IMA of Louisiana Commercial PPO 18.11 percent of total billed charges 11.72 18.11 Reimbursement at 85% of billed charges HYDROCODONE/ACET 7.5/325/15ML ELIXIR 250 RC 0121477215 NDC outpatient 7.5 ME 21.3 17.04 Aetna Commercial PPO 11.72 percent of total billed charges 11.72 18.11 55 of billed Charges SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC inpatient 1.5 ME 31.26 15.63 BCBS Louisiana PPO 15.63 percent of total billed charges 15.63 26.57 50% of Eligible Charges SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC outpatient 1.5 ME 31.26 25.01 BCBS Louisiana PPO 25.01 percent of total billed charges 17.19 26.57 80% of billed charge SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC outpatient 1.5 ME 31.26 25.01 Cigna Commercial PPO 17.19 percent of total billed charges 17.19 26.57 55% of Billed Charges SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC inpatient 1.5 ME 31.26 15.63 IMA of Louisiana Commercial PPO 26.57 percent of total billed charges 15.63 26.57 Inpatient Reimbursement at 85% of Billed Charges SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC outpatient 1.5 ME 31.26 25.01 IMA of Louisiana Commercial PPO 26.57 percent of total billed charges 17.19 26.57 Reimbursement at 85% of billed charges SCOPOLAMINE 1.5MG PATCH 250 RC 5074250524 NDC outpatient 1.5 ME 31.26 25.01 Aetna Commercial PPO 17.19 percent of total billed charges 17.19 26.57 55 of billed Charges CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC inpatient 0.1 ME 1.33 0.67 BCBS Louisiana PPO 0.67 percent of total billed charges 0.67 1.13 50% of Eligible Charges CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC outpatient 0.1 ME 1.33 1.06 BCBS Louisiana PPO 1.06 percent of total billed charges 0.73 1.13 80% of billed charge CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC outpatient 0.1 ME 1.33 1.06 Cigna Commercial PPO 0.73 percent of total billed charges 0.73 1.13 55% of Billed Charges CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC inpatient 0.1 ME 1.33 0.67 IMA of Louisiana Commercial PPO 1.13 percent of total billed charges 0.67 1.13 Inpatient Reimbursement at 85% of Billed Charges CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC outpatient 0.1 ME 1.33 1.06 IMA of Louisiana Commercial PPO 1.13 percent of total billed charges 0.73 1.13 Reimbursement at 85% of billed charges CLONIDINE 0.1MG TABLET 250 RC 6068711301 NDC outpatient 0.1 ME 1.33 1.06 Aetna Commercial PPO 0.73 percent of total billed charges 0.73 1.13 55 of billed Charges DEXTROSE SOL 5% 1000ML J7070 HCPCS 250 RC 0264751000 NDC inpatient 1000 ML 16.32 8.16 BCBS Louisiana PPO 8.16 percent of total billed charges 8.16 13.87 50% of Eligible Charges DEXTROSE SOL 5% 1000ML J7070 HCPCS 250 RC 0264751000 NDC outpatient 1000 ML 16.32 13.06 BCBS Louisiana PPO 13.06 percent of total billed charges 8.98 13.87 80% of billed charge DEXTROSE SOL 5% 1000ML J7070 HCPCS 250 RC 0264751000 NDC outpatient 1000 ML 16.32 13.06 Cigna Commercial PPO 8.98 percent of total billed charges 8.98 13.87 55% of Billed Charges DEXTROSE SOL 5% 1000ML J7070 HCPCS 250 RC 0264751000 NDC inpatient 1000 ML 16.32 8.16 IMA of Louisiana Commercial PPO 13.87 percent of total billed charges 8.16 13.87 Inpatient Reimbursement at 85% of Billed Charges DEXTROSE SOL 5% 1000ML J7070 HCPCS 250 RC 0264751000 NDC outpatient 1000 ML 16.32 13.06 IMA of Louisiana Commercial PPO 13.87 percent of total billed charges 8.98 13.87 Reimbursement at 85% of billed charges NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC inpatient 21 ME 7.67 3.84 BCBS Louisiana PPO 3.84 percent of total billed charges 3.84 6.52 50% of Eligible Charges NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC outpatient 21 ME 7.67 6.14 BCBS Louisiana PPO 6.14 percent of total billed charges 4.22 6.52 80% of billed charge NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC outpatient 21 ME 7.67 6.14 Cigna Commercial PPO 4.22 percent of total billed charges 4.22 6.52 55% of Billed Charges NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC inpatient 21 ME 7.67 3.84 IMA of Louisiana Commercial PPO 6.52 percent of total billed charges 3.84 6.52 Inpatient Reimbursement at 85% of Billed Charges NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC outpatient 21 ME 7.67 6.14 IMA of Louisiana Commercial PPO 6.52 percent of total billed charges 4.22 6.52 Reimbursement at 85% of billed charges NICOTINE 21MG/24HR PATCH 250 RC 0536589688 NDC outpatient 21 ME 7.67 6.14 Aetna Commercial PPO 4.22 percent of total billed charges 4.22 6.52 55 of billed Charges ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC inpatient 240 ME 107.2 53.6 BCBS Louisiana PPO 53.6 percent of total billed charges 53.6 91.12 50% of Eligible Charges ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC outpatient 240 ME 107.2 85.76 BCBS Louisiana PPO 85.76 percent of total billed charges 58.96 91.12 80% of billed charge ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC outpatient 240 ME 107.2 85.76 Cigna Commercial PPO 58.96 percent of total billed charges 58.96 91.12 55% of Billed Charges ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC inpatient 240 ME 107.2 53.6 IMA of Louisiana Commercial PPO 91.12 percent of total billed charges 53.6 91.12 Inpatient Reimbursement at 85% of Billed Charges ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC outpatient 240 ME 107.2 85.76 IMA of Louisiana Commercial PPO 91.12 percent of total billed charges 58.96 91.12 Reimbursement at 85% of billed charges ISOVUE-M 200 41% INJ : 20ML Q9966 HCPCS 636 RC 0407141210 NDC outpatient 240 ME 107.2 85.76 Aetna Commercial PPO 64.32 percent of total billed charges 58.96 91.12 60 Of Billed Charges DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC inpatient 1000 ML 16.15 8.08 BCBS Louisiana PPO 8.08 percent of total billed charges 8.08 13.73 50% of Eligible Charges DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC outpatient 1000 ML 16.15 12.92 BCBS Louisiana PPO 12.92 percent of total billed charges 8.88 13.73 80% of billed charge DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC outpatient 1000 ML 16.15 12.92 Cigna Commercial PPO 8.88 percent of total billed charges 8.88 13.73 55% of Billed Charges DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC inpatient 1000 ML 16.15 8.08 IMA of Louisiana Commercial PPO 13.73 percent of total billed charges 8.08 13.73 Inpatient Reimbursement at 85% of Billed Charges DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC outpatient 1000 ML 16.15 12.92 IMA of Louisiana Commercial PPO 13.73 percent of total billed charges 8.88 13.73 Reimbursement at 85% of billed charges DEXTROSE 5%/.45% SODIUM CHL 1000ML 260 RC 0338008504 NDC outpatient 1000 ML 16.15 12.92 Aetna Commercial PPO 8.88 percent of total billed charges 8.88 13.73 55 of billed Charges FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FLUOXETINE 20MG CAPSULE 250 RC 0904578561 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ESCITALOPRAM 10MG TABLET 250 RC 0904642661 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC inpatient 180 ME 2.26 1.13 BCBS Louisiana PPO 1.13 percent of total billed charges 1.13 1.92 50% of Eligible Charges FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC outpatient 180 ME 2.26 1.81 BCBS Louisiana PPO 1.81 percent of total billed charges 1.24 1.92 80% of billed charge FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC outpatient 180 ME 2.26 1.81 Cigna Commercial PPO 1.24 percent of total billed charges 1.24 1.92 55% of Billed Charges FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC inpatient 180 ME 2.26 1.13 IMA of Louisiana Commercial PPO 1.92 percent of total billed charges 1.13 1.92 Inpatient Reimbursement at 85% of Billed Charges FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC outpatient 180 ME 2.26 1.81 IMA of Louisiana Commercial PPO 1.92 percent of total billed charges 1.24 1.92 Reimbursement at 85% of billed charges FEXOFENADINE 180MG TAB 250 RC 5107954820 NDC outpatient 180 ME 2.26 1.81 Aetna Commercial PPO 1.24 percent of total billed charges 1.24 1.92 55 of billed Charges LEVOFLOXACIN 500MG IVPB J1956 HCPCS 250 RC 4456743624 NDC inpatient 500 ME 18.48 9.24 BCBS Louisiana PPO 9.24 percent of total billed charges 9.24 15.71 50% of Eligible Charges LEVOFLOXACIN 500MG IVPB J1956 HCPCS 250 RC 4456743624 NDC outpatient 500 ME 18.48 14.78 BCBS Louisiana PPO 14.78 percent of total billed charges 10.16 15.71 80% of billed charge LEVOFLOXACIN 500MG IVPB J1956 HCPCS 250 RC 4456743624 NDC outpatient 500 ME 18.48 14.78 Cigna Commercial PPO 10.16 percent of total billed charges 10.16 15.71 55% of Billed Charges LEVOFLOXACIN 500MG IVPB J1956 HCPCS 250 RC 4456743624 NDC inpatient 500 ME 18.48 9.24 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 9.24 15.71 Inpatient Reimbursement at 85% of Billed Charges LEVOFLOXACIN 500MG IVPB J1956 HCPCS 250 RC 4456743624 NDC outpatient 500 ME 18.48 14.78 IMA of Louisiana Commercial PPO 15.71 percent of total billed charges 10.16 15.71 Reimbursement at 85% of billed charges LABETALOL 200MG TABLET 250 RC 6800138203 NDC inpatient 200 ME 2.72 1.36 BCBS Louisiana PPO 1.36 percent of total billed charges 1.36 2.31 50% of Eligible Charges LABETALOL 200MG TABLET 250 RC 6800138203 NDC outpatient 200 ME 2.72 2.18 BCBS Louisiana PPO 2.18 percent of total billed charges 1.5 2.31 80% of billed charge LABETALOL 200MG TABLET 250 RC 6800138203 NDC outpatient 200 ME 2.72 2.18 Cigna Commercial PPO 1.5 percent of total billed charges 1.5 2.31 55% of Billed Charges LABETALOL 200MG TABLET 250 RC 6800138203 NDC inpatient 200 ME 2.72 1.36 IMA of Louisiana Commercial PPO 2.31 percent of total billed charges 1.36 2.31 Inpatient Reimbursement at 85% of Billed Charges LABETALOL 200MG TABLET 250 RC 6800138203 NDC outpatient 200 ME 2.72 2.18 IMA of Louisiana Commercial PPO 2.31 percent of total billed charges 1.5 2.31 Reimbursement at 85% of billed charges LABETALOL 200MG TABLET 250 RC 6800138203 NDC outpatient 200 ME 2.72 2.18 Aetna Commercial PPO 1.5 percent of total billed charges 1.5 2.31 55 of billed Charges LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC inpatient 500 ME 2.27 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 1.14 1.93 50% of Eligible Charges LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC outpatient 500 ME 2.27 1.82 BCBS Louisiana PPO 1.82 percent of total billed charges 1.25 1.93 80% of billed charge LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC outpatient 500 ME 2.27 1.82 Cigna Commercial PPO 1.25 percent of total billed charges 1.25 1.93 55% of Billed Charges LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC inpatient 500 ME 2.27 1.14 IMA of Louisiana Commercial PPO 1.93 percent of total billed charges 1.14 1.93 Inpatient Reimbursement at 85% of Billed Charges LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC outpatient 500 ME 2.27 1.82 IMA of Louisiana Commercial PPO 1.93 percent of total billed charges 1.25 1.93 Reimbursement at 85% of billed charges LEVOFLOXACIN 500MG TABLET 250 RC 0904635261 NDC outpatient 500 ME 2.27 1.82 Aetna Commercial PPO 1.25 percent of total billed charges 1.25 1.93 55 of billed Charges BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC inpatient 20 ME 2.81 1.41 BCBS Louisiana PPO 1.41 percent of total billed charges 1.41 2.39 50% of Eligible Charges BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC outpatient 20 ME 2.81 2.25 BCBS Louisiana PPO 2.25 percent of total billed charges 1.55 2.39 80% of billed charge BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC outpatient 20 ME 2.81 2.25 Cigna Commercial PPO 1.55 percent of total billed charges 1.55 2.39 55% of Billed Charges BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC inpatient 20 ME 2.81 1.41 IMA of Louisiana Commercial PPO 2.39 percent of total billed charges 1.41 2.39 Inpatient Reimbursement at 85% of Billed Charges BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC outpatient 20 ME 2.81 2.25 IMA of Louisiana Commercial PPO 2.39 percent of total billed charges 1.55 2.39 Reimbursement at 85% of billed charges BENAZEPRIL 20MG TABLET 250 RC 5026811115 NDC outpatient 20 ME 2.81 2.25 Aetna Commercial PPO 1.55 percent of total billed charges 1.55 2.39 55 of billed Charges ROPIVACAINE 0.2% 200ML J2795 HCPCS 250 RC 2502167187 NDC inpatient 400 ME 149.57 74.79 BCBS Louisiana PPO 74.79 percent of total billed charges 74.79 127.13 50% of Eligible Charges ROPIVACAINE 0.2% 200ML J2795 HCPCS 250 RC 2502167187 NDC outpatient 400 ME 149.57 119.66 BCBS Louisiana PPO 119.66 percent of total billed charges 82.26 127.13 80% of billed charge ROPIVACAINE 0.2% 200ML J2795 HCPCS 250 RC 2502167187 NDC outpatient 400 ME 149.57 119.66 Cigna Commercial PPO 82.26 percent of total billed charges 82.26 127.13 55% of Billed Charges ROPIVACAINE 0.2% 200ML J2795 HCPCS 250 RC 2502167187 NDC inpatient 400 ME 149.57 74.79 IMA of Louisiana Commercial PPO 127.13 percent of total billed charges 74.79 127.13 Inpatient Reimbursement at 85% of Billed Charges ROPIVACAINE 0.2% 200ML J2795 HCPCS 250 RC 2502167187 NDC outpatient 400 ME 149.57 119.66 IMA of Louisiana Commercial PPO 127.13 percent of total billed charges 82.26 127.13 Reimbursement at 85% of billed charges SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC inpatient 80 ME 1.26 0.63 BCBS Louisiana PPO 0.63 percent of total billed charges 0.63 1.07 50% of Eligible Charges SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC outpatient 80 ME 1.26 1.01 BCBS Louisiana PPO 1.01 percent of total billed charges 0.69 1.07 80% of billed charge SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC outpatient 80 ME 1.26 1.01 Cigna Commercial PPO 0.69 percent of total billed charges 0.69 1.07 55% of Billed Charges SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC inpatient 80 ME 1.26 0.63 IMA of Louisiana Commercial PPO 1.07 percent of total billed charges 0.63 1.07 Inpatient Reimbursement at 85% of Billed Charges SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC outpatient 80 ME 1.26 1.01 IMA of Louisiana Commercial PPO 1.07 percent of total billed charges 0.69 1.07 Reimbursement at 85% of billed charges SULFAMETHOXAZOLE/TRIM 400/80MG TABLET 250 RC 5026872811 NDC outpatient 80 ME 1.26 1.01 Aetna Commercial PPO 0.69 percent of total billed charges 0.69 1.07 55 of billed Charges HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC inpatient 200 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC outpatient 200 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC outpatient 200 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC inpatient 200 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC outpatient 200 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HYDROXYCHLOROQUINE 200MG TABLET 250 RC 6838209601 NDC outpatient 200 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC inpatient 1 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC outpatient 1 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC outpatient 1 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC inpatient 1 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC outpatient 1 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FOLIC ACID 1MG TABLET 250 RC 0904722461 NDC outpatient 1 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC inpatient 300 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC outpatient 300 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC outpatient 300 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC inpatient 300 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC outpatient 300 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges GABAPENTIN 300MG CAPSULE 250 RC 6068759101 NDC outpatient 300 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC inpatient 7.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC outpatient 7.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC outpatient 7.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC inpatient 7.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC outpatient 7.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MELOXICAM 7.5MG TABLET 250 RC 5026852511 NDC outpatient 7.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges TRAMADOL 50MG TABLET 250 RC 6068779511 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TRAMADOL 50MG TABLET 250 RC 6068779511 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TRAMADOL 50MG TABLET 250 RC 6068779511 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TRAMADOL 50MG TABLET 250 RC 6068779511 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TRAMADOL 50MG TABLET 250 RC 6068779511 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TRAMADOL 50MG TABLET 250 RC 6068779511 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ABACAVIR 300MG TAB NON-FORMULARY J8499 HCPCS 250 RC 5486845220 NDC inpatient 300 ME 12 6 BCBS Louisiana PPO 6 percent of total billed charges 6 10.2 50% of Eligible Charges ABACAVIR 300MG TAB NON-FORMULARY J8499 HCPCS 250 RC 5486845220 NDC outpatient 300 ME 12 9.6 BCBS Louisiana PPO 9.6 percent of total billed charges 6.6 10.2 80% of billed charge ABACAVIR 300MG TAB NON-FORMULARY J8499 HCPCS 250 RC 5486845220 NDC outpatient 300 ME 12 9.6 Cigna Commercial PPO 6.6 percent of total billed charges 6.6 10.2 55% of Billed Charges ABACAVIR 300MG TAB NON-FORMULARY J8499 HCPCS 250 RC 5486845220 NDC inpatient 300 ME 12 6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6 10.2 Inpatient Reimbursement at 85% of Billed Charges ABACAVIR 300MG TAB NON-FORMULARY J8499 HCPCS 250 RC 5486845220 NDC outpatient 300 ME 12 9.6 IMA of Louisiana Commercial PPO 10.2 percent of total billed charges 6.6 10.2 Reimbursement at 85% of billed charges PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC inpatient 150 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC outpatient 150 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC outpatient 150 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC inpatient 150 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC outpatient 150 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PROPAFENONE 150MG TABLET 250 RC 6255923001 NDC outpatient 150 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC inpatient 200 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC outpatient 200 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC outpatient 200 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC inpatient 200 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC outpatient 200 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CELECOXIB 200MG CAPSULE 250 RC 6936730201 NDC outpatient 200 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC inpatient 40 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC outpatient 40 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC outpatient 40 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC inpatient 40 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC outpatient 40 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TELMISARTAN 40MG TABLET 250 RC 4354728403 NDC outpatient 40 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC inpatient 300 ME 6.37 3.19 BCBS Louisiana PPO 3.19 percent of total billed charges 3.19 5.41 50% of Eligible Charges CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC outpatient 300 ME 6.37 5.1 BCBS Louisiana PPO 5.1 percent of total billed charges 3.5 5.41 80% of billed charge CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC outpatient 300 ME 6.37 5.1 Cigna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55% of Billed Charges CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC inpatient 300 ME 6.37 3.19 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.19 5.41 Inpatient Reimbursement at 85% of Billed Charges CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC outpatient 300 ME 6.37 5.1 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.5 5.41 Reimbursement at 85% of billed charges CLINDAMYCIN 300MG CAP 250 RC 7093404840 NDC outpatient 300 ME 6.37 5.1 Aetna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55 of billed Charges VALSARTAN 40MG TABLET 250 RC 3334206207 NDC inpatient 40 ME 1.37 0.69 BCBS Louisiana PPO 0.69 percent of total billed charges 0.69 1.16 50% of Eligible Charges VALSARTAN 40MG TABLET 250 RC 3334206207 NDC outpatient 40 ME 1.37 1.1 BCBS Louisiana PPO 1.1 percent of total billed charges 0.75 1.16 80% of billed charge VALSARTAN 40MG TABLET 250 RC 3334206207 NDC outpatient 40 ME 1.37 1.1 Cigna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55% of Billed Charges VALSARTAN 40MG TABLET 250 RC 3334206207 NDC inpatient 40 ME 1.37 0.69 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.69 1.16 Inpatient Reimbursement at 85% of Billed Charges VALSARTAN 40MG TABLET 250 RC 3334206207 NDC outpatient 40 ME 1.37 1.1 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.75 1.16 Reimbursement at 85% of billed charges VALSARTAN 40MG TABLET 250 RC 3334206207 NDC outpatient 40 ME 1.37 1.1 Aetna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55 of billed Charges FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC inpatient 160 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC outpatient 160 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC outpatient 160 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC inpatient 160 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC outpatient 160 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FENOFIBRATE 160MG TABLET 250 RC 2724111703 NDC outpatient 160 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC inpatient 25 ME 1.02 0.51 BCBS Louisiana PPO 0.51 percent of total billed charges 0.51 0.87 50% of Eligible Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 25 ME 1.02 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.56 0.87 80% of billed charge SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 25 ME 1.02 0.82 Cigna Commercial PPO 0.56 percent of total billed charges 0.56 0.87 55% of Billed Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC inpatient 25 ME 1.02 0.51 IMA of Louisiana Commercial PPO 0.87 percent of total billed charges 0.51 0.87 Inpatient Reimbursement at 85% of Billed Charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 25 ME 1.02 0.82 IMA of Louisiana Commercial PPO 0.87 percent of total billed charges 0.56 0.87 Reimbursement at 85% of billed charges SINEMET 25/100 TAB NON-FORMULARY 250 RC 6068766111 NDC outpatient 25 ME 1.02 0.82 Aetna Commercial PPO 0.56 percent of total billed charges 0.56 0.87 55 of billed Charges DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC inpatient 120 ME 1.44 0.72 BCBS Louisiana PPO 0.72 percent of total billed charges 0.72 1.22 50% of Eligible Charges DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC outpatient 120 ME 1.44 1.15 BCBS Louisiana PPO 1.15 percent of total billed charges 0.79 1.22 80% of billed charge DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC outpatient 120 ME 1.44 1.15 Cigna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55% of Billed Charges DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC inpatient 120 ME 1.44 0.72 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.72 1.22 Inpatient Reimbursement at 85% of Billed Charges DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC outpatient 120 ME 1.44 1.15 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.79 1.22 Reimbursement at 85% of billed charges DILTIAZEM CD 120MG CAPSULE 250 RC 6068719511 NDC outpatient 120 ME 1.44 1.15 Aetna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55 of billed Charges LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LORAZEPAM 0.5MG TABLET 250 RC 6931590401 NDC outpatient 0.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LIDOCAINE 1% W/EPI 20ML J2001 HCPCS 250 RC 6332348227 NDC inpatient 10 ML 26.84 13.42 BCBS Louisiana PPO 13.42 percent of total billed charges 13.42 22.81 50% of Eligible Charges LIDOCAINE 1% W/EPI 20ML J2001 HCPCS 250 RC 6332348227 NDC outpatient 10 ML 26.84 21.47 BCBS Louisiana PPO 21.47 percent of total billed charges 14.76 22.81 80% of billed charge LIDOCAINE 1% W/EPI 20ML J2001 HCPCS 250 RC 6332348227 NDC outpatient 10 ML 26.84 21.47 Cigna Commercial PPO 14.76 percent of total billed charges 14.76 22.81 55% of Billed Charges LIDOCAINE 1% W/EPI 20ML J2001 HCPCS 250 RC 6332348227 NDC inpatient 10 ML 26.84 13.42 IMA of Louisiana Commercial PPO 22.81 percent of total billed charges 13.42 22.81 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 1% W/EPI 20ML J2001 HCPCS 250 RC 6332348227 NDC outpatient 10 ML 26.84 21.47 IMA of Louisiana Commercial PPO 22.81 percent of total billed charges 14.76 22.81 Reimbursement at 85% of billed charges HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC inpatient 3 ML 104.93 52.47 BCBS Louisiana PPO 52.47 percent of total billed charges 52.47 89.19 50% of Eligible Charges HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC outpatient 3 ML 104.93 83.94 BCBS Louisiana PPO 83.94 percent of total billed charges 57.71 89.19 80% of billed charge HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC outpatient 3 ML 104.93 83.94 Cigna Commercial PPO 57.71 percent of total billed charges 57.71 89.19 55% of Billed Charges HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC inpatient 3 ML 104.93 52.47 IMA of Louisiana Commercial PPO 89.19 percent of total billed charges 52.47 89.19 Inpatient Reimbursement at 85% of Billed Charges HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC outpatient 3 ML 104.93 83.94 IMA of Louisiana Commercial PPO 89.19 percent of total billed charges 57.71 89.19 Reimbursement at 85% of billed charges HUMULIN-N 100U/ML 3ML SYRINGE 250 RC 0002880559 NDC outpatient 3 ML 104.93 83.94 Aetna Commercial PPO 57.71 percent of total billed charges 57.71 89.19 55 of billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LINZESS 145MCG CAP 250 RC 0456120130 NDC inpatient 145 UN 54.21 27.11 BCBS Louisiana PPO 27.11 percent of total billed charges 27.11 46.08 50% of Eligible Charges LINZESS 145MCG CAP 250 RC 0456120130 NDC outpatient 145 UN 54.21 43.37 BCBS Louisiana PPO 43.37 percent of total billed charges 29.82 46.08 80% of billed charge LINZESS 145MCG CAP 250 RC 0456120130 NDC outpatient 145 UN 54.21 43.37 Cigna Commercial PPO 29.82 percent of total billed charges 29.82 46.08 55% of Billed Charges LINZESS 145MCG CAP 250 RC 0456120130 NDC inpatient 145 UN 54.21 27.11 IMA of Louisiana Commercial PPO 46.08 percent of total billed charges 27.11 46.08 Inpatient Reimbursement at 85% of Billed Charges LINZESS 145MCG CAP 250 RC 0456120130 NDC outpatient 145 UN 54.21 43.37 IMA of Louisiana Commercial PPO 46.08 percent of total billed charges 29.82 46.08 Reimbursement at 85% of billed charges LINZESS 145MCG CAP 250 RC 0456120130 NDC outpatient 145 UN 54.21 43.37 Aetna Commercial PPO 29.82 percent of total billed charges 29.82 46.08 55 of billed Charges PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PRIMIDONE 50MG TABLET 250 RC 7288804501 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC inpatient 4.5 UN 351.42 175.71 BCBS Louisiana PPO 175.71 percent of total billed charges 175.71 298.71 50% of Eligible Charges SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC outpatient 4.5 UN 351.42 281.14 BCBS Louisiana PPO 281.14 percent of total billed charges 193.28 298.71 80% of billed charge SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC outpatient 4.5 UN 351.42 281.14 Cigna Commercial PPO 193.28 percent of total billed charges 193.28 298.71 55% of Billed Charges SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC inpatient 4.5 UN 351.42 175.71 IMA of Louisiana Commercial PPO 298.71 percent of total billed charges 175.71 298.71 Inpatient Reimbursement at 85% of Billed Charges SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC outpatient 4.5 UN 351.42 281.14 IMA of Louisiana Commercial PPO 298.71 percent of total billed charges 193.28 298.71 Reimbursement at 85% of billed charges SYMBICORT 160/4.5MCG INHALER 250 RC 0186037028 NDC outpatient 4.5 UN 351.42 281.14 Aetna Commercial PPO 193.28 percent of total billed charges 193.28 298.71 55 of billed Charges GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC inpatient 20 ME 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC outpatient 20 ME 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC outpatient 20 ME 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC inpatient 20 ME 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC outpatient 20 ME 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges GEODON 20MG CAP NON-FORMULARY 250 RC 5511125660 NDC outpatient 20 ME 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC inpatient 15 ML 25.24 12.62 BCBS Louisiana PPO 12.62 percent of total billed charges 12.62 21.45 50% of Eligible Charges SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC outpatient 15 ML 25.24 20.19 BCBS Louisiana PPO 20.19 percent of total billed charges 13.88 21.45 80% of billed charge SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC outpatient 15 ML 25.24 20.19 Cigna Commercial PPO 13.88 percent of total billed charges 13.88 21.45 55% of Billed Charges SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC inpatient 15 ML 25.24 12.62 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 12.62 21.45 Inpatient Reimbursement at 85% of Billed Charges SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC outpatient 15 ML 25.24 20.19 IMA of Louisiana Commercial PPO 21.45 percent of total billed charges 13.88 21.45 Reimbursement at 85% of billed charges SODIUM CITRATE W/ CITRIC ACID 15ML UD NF 250 RC 0121059500 NDC outpatient 15 ML 25.24 20.19 Aetna Commercial PPO 13.88 percent of total billed charges 13.88 21.45 55 of billed Charges HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC inpatient 325 ME 3.06 1.53 BCBS Louisiana PPO 1.53 percent of total billed charges 1.53 2.6 50% of Eligible Charges HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC outpatient 325 ME 3.06 2.45 BCBS Louisiana PPO 2.45 percent of total billed charges 1.68 2.6 80% of billed charge HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC outpatient 325 ME 3.06 2.45 Cigna Commercial PPO 1.68 percent of total billed charges 1.68 2.6 55% of Billed Charges HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC inpatient 325 ME 3.06 1.53 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.53 2.6 Inpatient Reimbursement at 85% of Billed Charges HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC outpatient 325 ME 3.06 2.45 IMA of Louisiana Commercial PPO 2.6 percent of total billed charges 1.68 2.6 Reimbursement at 85% of billed charges HYDROCODONE/ACET 10/325MG TABLET 250 RC 6068741801 NDC outpatient 325 ME 3.06 2.45 Aetna Commercial PPO 1.68 percent of total billed charges 1.68 2.6 55 of billed Charges PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PRAMIPEXOLE 0.5MG TABLET 250 RC 1366809390 NDC outpatient 0.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DEXILANT 30MG CAP 250 RC 2497900106 NDC inpatient 30 ME 30 15 BCBS Louisiana PPO 15 percent of total billed charges 15 25.5 50% of Eligible Charges DEXILANT 30MG CAP 250 RC 2497900106 NDC outpatient 30 ME 30 24 BCBS Louisiana PPO 24 percent of total billed charges 16.5 25.5 80% of billed charge DEXILANT 30MG CAP 250 RC 2497900106 NDC outpatient 30 ME 30 24 Cigna Commercial PPO 16.5 percent of total billed charges 16.5 25.5 55% of Billed Charges DEXILANT 30MG CAP 250 RC 2497900106 NDC inpatient 30 ME 30 15 IMA of Louisiana Commercial PPO 25.5 percent of total billed charges 15 25.5 Inpatient Reimbursement at 85% of Billed Charges DEXILANT 30MG CAP 250 RC 2497900106 NDC outpatient 30 ME 30 24 IMA of Louisiana Commercial PPO 25.5 percent of total billed charges 16.5 25.5 Reimbursement at 85% of billed charges DEXILANT 30MG CAP 250 RC 2497900106 NDC outpatient 30 ME 30 24 Aetna Commercial PPO 16.5 percent of total billed charges 16.5 25.5 55 of billed Charges ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC inpatient 20 ME 2.87 1.44 BCBS Louisiana PPO 1.44 percent of total billed charges 1.44 2.44 50% of Eligible Charges ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC outpatient 20 ME 2.87 2.3 BCBS Louisiana PPO 2.3 percent of total billed charges 1.58 2.44 80% of billed charge ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC outpatient 20 ME 2.87 2.3 Cigna Commercial PPO 1.58 percent of total billed charges 1.58 2.44 55% of Billed Charges ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC inpatient 20 ME 2.87 1.44 IMA of Louisiana Commercial PPO 2.44 percent of total billed charges 1.44 2.44 Inpatient Reimbursement at 85% of Billed Charges ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC outpatient 20 ME 2.87 2.3 IMA of Louisiana Commercial PPO 2.44 percent of total billed charges 1.58 2.44 Reimbursement at 85% of billed charges ISOSORBIDE DINITRATE 20MG TABLET 250 RC 6373936710 NDC outpatient 20 ME 2.87 2.3 Aetna Commercial PPO 1.58 percent of total billed charges 1.58 2.44 55 of billed Charges BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC inpatient 150 ME 7.74 3.87 BCBS Louisiana PPO 3.87 percent of total billed charges 3.87 6.58 50% of Eligible Charges BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC outpatient 150 ME 7.74 6.19 BCBS Louisiana PPO 6.19 percent of total billed charges 4.26 6.58 80% of billed charge BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC outpatient 150 ME 7.74 6.19 Cigna Commercial PPO 4.26 percent of total billed charges 4.26 6.58 55% of Billed Charges BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC inpatient 150 ME 7.74 3.87 IMA of Louisiana Commercial PPO 6.58 percent of total billed charges 3.87 6.58 Inpatient Reimbursement at 85% of Billed Charges BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC outpatient 150 ME 7.74 6.19 IMA of Louisiana Commercial PPO 6.58 percent of total billed charges 4.26 6.58 Reimbursement at 85% of billed charges BUPROPION HCL SR 150MG TABLET 250 RC 6068778211 NDC outpatient 150 ME 7.74 6.19 Aetna Commercial PPO 4.26 percent of total billed charges 4.26 6.58 55 of billed Charges DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DONEPEZIL 10MG TABLET 250 RC 0904647861 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC inpatient 15 ML 19.98 9.99 BCBS Louisiana PPO 9.99 percent of total billed charges 9.99 16.98 50% of Eligible Charges PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC outpatient 15 ML 19.98 15.98 BCBS Louisiana PPO 15.98 percent of total billed charges 10.99 16.98 80% of billed charge PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC outpatient 15 ML 19.98 15.98 Cigna Commercial PPO 10.99 percent of total billed charges 10.99 16.98 55% of Billed Charges PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC inpatient 15 ML 19.98 9.99 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 9.99 16.98 Inpatient Reimbursement at 85% of Billed Charges PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC outpatient 15 ML 19.98 15.98 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 10.99 16.98 Reimbursement at 85% of billed charges PHENYLEPHRINE .25% SPRAY 15ML 250 RC 0225080047 NDC outpatient 15 ML 19.98 15.98 Aetna Commercial PPO 10.99 percent of total billed charges 10.99 16.98 55 of billed Charges ACETAMINOPHEN 160MG/5ML ELIXIR J8499 HCPCS 250 RC 0121178100 NDC inpatient 5 ML 3.88 1.94 BCBS Louisiana PPO 1.94 percent of total billed charges 1.94 3.3 50% of Eligible Charges ACETAMINOPHEN 160MG/5ML ELIXIR J8499 HCPCS 250 RC 0121178100 NDC outpatient 5 ML 3.88 3.1 BCBS Louisiana PPO 3.1 percent of total billed charges 2.13 3.3 80% of billed charge ACETAMINOPHEN 160MG/5ML ELIXIR J8499 HCPCS 250 RC 0121178100 NDC outpatient 5 ML 3.88 3.1 Cigna Commercial PPO 2.13 percent of total billed charges 2.13 3.3 55% of Billed Charges ACETAMINOPHEN 160MG/5ML ELIXIR J8499 HCPCS 250 RC 0121178100 NDC inpatient 5 ML 3.88 1.94 IMA of Louisiana Commercial PPO 3.3 percent of total billed charges 1.94 3.3 Inpatient Reimbursement at 85% of Billed Charges ACETAMINOPHEN 160MG/5ML ELIXIR J8499 HCPCS 250 RC 0121178100 NDC outpatient 5 ML 3.88 3.1 IMA of Louisiana Commercial PPO 3.3 percent of total billed charges 2.13 3.3 Reimbursement at 85% of billed charges SODIUM CHL 3% 500ML 260 RC 0338005403 NDC inpatient 500 ML 19.98 9.99 BCBS Louisiana PPO 9.99 percent of total billed charges 9.99 16.98 50% of Eligible Charges SODIUM CHL 3% 500ML 260 RC 0338005403 NDC outpatient 500 ML 19.98 15.98 BCBS Louisiana PPO 15.98 percent of total billed charges 10.99 16.98 80% of billed charge SODIUM CHL 3% 500ML 260 RC 0338005403 NDC outpatient 500 ML 19.98 15.98 Cigna Commercial PPO 10.99 percent of total billed charges 10.99 16.98 55% of Billed Charges SODIUM CHL 3% 500ML 260 RC 0338005403 NDC inpatient 500 ML 19.98 9.99 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 9.99 16.98 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 3% 500ML 260 RC 0338005403 NDC outpatient 500 ML 19.98 15.98 IMA of Louisiana Commercial PPO 16.98 percent of total billed charges 10.99 16.98 Reimbursement at 85% of billed charges SODIUM CHL 3% 500ML 260 RC 0338005403 NDC outpatient 500 ML 19.98 15.98 Aetna Commercial PPO 10.99 percent of total billed charges 10.99 16.98 55 of billed Charges MODURETIC 5/50MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0378057701 NDC inpatient 50 ME 22.48 11.24 BCBS Louisiana PPO 11.24 percent of total billed charges 11.24 19.11 50% of Eligible Charges MODURETIC 5/50MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0378057701 NDC outpatient 50 ME 22.48 17.98 BCBS Louisiana PPO 17.98 percent of total billed charges 12.36 19.11 80% of billed charge MODURETIC 5/50MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0378057701 NDC outpatient 50 ME 22.48 17.98 Cigna Commercial PPO 12.36 percent of total billed charges 12.36 19.11 55% of Billed Charges MODURETIC 5/50MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0378057701 NDC inpatient 50 ME 22.48 11.24 IMA of Louisiana Commercial PPO 19.11 percent of total billed charges 11.24 19.11 Inpatient Reimbursement at 85% of Billed Charges MODURETIC 5/50MG TAB NON-FORMULARY J8499 HCPCS 250 RC 0378057701 NDC outpatient 50 ME 22.48 17.98 IMA of Louisiana Commercial PPO 19.11 percent of total billed charges 12.36 19.11 Reimbursement at 85% of billed charges VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC inpatient 120 ME 1.34 0.67 BCBS Louisiana PPO 0.67 percent of total billed charges 0.67 1.14 50% of Eligible Charges VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC outpatient 120 ME 1.34 1.07 BCBS Louisiana PPO 1.07 percent of total billed charges 0.74 1.14 80% of billed charge VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC outpatient 120 ME 1.34 1.07 Cigna Commercial PPO 0.74 percent of total billed charges 0.74 1.14 55% of Billed Charges VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC inpatient 120 ME 1.34 0.67 IMA of Louisiana Commercial PPO 1.14 percent of total billed charges 0.67 1.14 Inpatient Reimbursement at 85% of Billed Charges VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC outpatient 120 ME 1.34 1.07 IMA of Louisiana Commercial PPO 1.14 percent of total billed charges 0.74 1.14 Reimbursement at 85% of billed charges VERAPAMIL ER 120MG TABLET 250 RC 6846229201 NDC outpatient 120 ME 1.34 1.07 Aetna Commercial PPO 0.74 percent of total billed charges 0.74 1.14 55 of billed Charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC inpatient 5621.13 2810.57 BCBS Louisiana PPO 2810.57 percent of total billed charges 2810.57 4777.96 50% of Eligible Charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC outpatient 5621.13 4496.9 BCBS Louisiana PPO 4496.9 percent of total billed charges 1300 4777.96 80% of billed charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC outpatient 5621.13 4496.9 Cigna Commercial PPO 3091.62 percent of total billed charges 1300 4777.96 55% of Billed Charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC inpatient 5621.13 2810.57 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 2810.57 4777.96 Inpatient Reimbursement at 85% of Billed Charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC outpatient 5621.13 4496.9 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 1300 4777.96 Reimbursement at 85% of billed charges DX INNERVUE ARTHROSCOPY KNEE 29870 CPT 360 RC outpatient 5621.13 4496.9 Aetna Commercial PPO 1300 fee schedule 1300 4777.96 Case Rate "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC inpatient 4430.75 2215.38 BCBS Louisiana PPO 2215.38 percent of total billed charges 2215.38 3766.14 50% of Eligible Charges "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC outpatient 4430.75 3544.6 BCBS Louisiana PPO 3544.6 percent of total billed charges 1300 3766.14 80% of billed charges "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC outpatient 4430.75 3544.6 Cigna Commercial PPO 2436.91 percent of total billed charges 1300 3766.14 55% of Billed Charges "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC inpatient 4430.75 2215.38 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 2215.38 3766.14 Inpatient Reimbursement at 85% of Billed Charges "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC outpatient 4430.75 3544.6 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 1300 3766.14 Reimbursement at 85% of billed charges "SHOULDER ARTHROSCOPY, DX" 29805 CPT 360 RC outpatient 4430.75 3544.6 Aetna Commercial PPO 1300 fee schedule 1300 3766.14 Case Rate WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC inpatient 3172.35 1586.18 BCBS Louisiana PPO 1586.18 percent of total billed charges 1586.18 2696.5 50% of Eligible Charges WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC outpatient 3172.35 2537.88 BCBS Louisiana PPO 2537.88 percent of total billed charges 1300 2696.5 80% of billed charges WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC outpatient 3172.35 2537.88 Cigna Commercial PPO 1744.79 percent of total billed charges 1300 2696.5 55% of Billed Charges WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC inpatient 3172.35 1586.18 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1586.18 2696.5 Inpatient Reimbursement at 85% of Billed Charges WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC outpatient 3172.35 2537.88 IMA of Louisiana Commercial PPO 2696.5 percent of total billed charges 1300 2696.5 Reimbursement at 85% of billed charges WRIST ENDOSCOPY/SURGERY 29848 CPT 360 RC outpatient 3172.35 2537.88 Aetna Commercial PPO 1300 fee schedule 1300 2696.5 Case Rate INJECT SPINE C/T 62310 CPT 360 RC inpatient 2196.08 1098.04 BCBS Louisiana PPO 1098.04 percent of total billed charges 1098.04 1866.67 50% of Eligible Charges INJECT SPINE C/T 62310 CPT 360 RC outpatient 2196.08 1756.86 BCBS Louisiana PPO 1756.86 percent of total billed charges 1207.84 1866.67 80% of billed charge INJECT SPINE C/T 62310 CPT 360 RC outpatient 2196.08 1756.86 Cigna Commercial PPO 1207.84 percent of total billed charges 1207.84 1866.67 55% of Billed Charges INJECT SPINE C/T 62310 CPT 360 RC inpatient 2196.08 1098.04 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1098.04 1866.67 Inpatient Reimbursement at 85% of Billed Charges INJECT SPINE C/T 62310 CPT 360 RC outpatient 2196.08 1756.86 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1207.84 1866.67 Reimbursement at 85% of billed charges INJECT SPINE C/T 62310 CPT 360 RC outpatient 2196.08 1756.86 Aetna Commercial PPO 1207.84 percent of total billed charges 1207.84 1866.67 55 of billed Charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC inpatient 59270.05 29635.03 BCBS Louisiana PPO 29635.03 percent of total billed charges 29635.03 50379.54 50% of Eligible Charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC outpatient 59270.05 47416.04 BCBS Louisiana PPO 47416.04 percent of total billed charges 1300 50379.54 80% of billed charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC outpatient 59270.05 47416.04 Cigna Commercial PPO 32598.53 percent of total billed charges 1300 50379.54 55% of Billed Charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC inpatient 59270.05 29635.03 IMA of Louisiana Commercial PPO 50379.54 percent of total billed charges 29635.03 50379.54 Inpatient Reimbursement at 85% of Billed Charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC outpatient 59270.05 47416.04 IMA of Louisiana Commercial PPO 50379.54 percent of total billed charges 1300 50379.54 Reimbursement at 85% of billed charges INSRT/REDO SPINE N GENERATOR 63685 CPT 360 RC outpatient 59270.05 47416.04 Aetna Commercial PPO 1300 fee schedule 1300 50379.54 Case Rate DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC inpatient 2196.08 1098.04 BCBS Louisiana PPO 1098.04 percent of total billed charges 1098.04 1866.67 50% of Eligible Charges DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC outpatient 2196.08 1756.86 BCBS Louisiana PPO 1756.86 percent of total billed charges 1207.84 1866.67 80% of billed charges DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC outpatient 2196.08 1756.86 Cigna Commercial PPO 1207.84 percent of total billed charges 1207.84 1866.67 55% of Billed Charges DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC inpatient 2196.08 1098.04 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1098.04 1866.67 Inpatient Reimbursement at 85% of Billed Charges DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC outpatient 2196.08 1756.86 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1207.84 1866.67 Reimbursement at 85% of billed charges DESTR PARAVERTEBRAL N ADD-ON 64634 CPT 360 RC outpatient 2196.08 1756.86 Aetna Commercial PPO 1300 fee schedule 1207.84 1866.67 Case Rate DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC inpatient 3368.12 1684.06 BCBS Louisiana PPO 1684.06 percent of total billed charges 1684.06 2862.9 50% of Eligible Charges DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC outpatient 3368.12 2694.5 BCBS Louisiana PPO 2694.5 percent of total billed charges 1300 2862.9 80% of billed charges DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC outpatient 3368.12 2694.5 Cigna Commercial PPO 1852.47 percent of total billed charges 1300 2862.9 55% of Billed Charges DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC inpatient 3368.12 1684.06 IMA of Louisiana Commercial PPO 2862.9 percent of total billed charges 1684.06 2862.9 Inpatient Reimbursement at 85% of Billed Charges DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC outpatient 3368.12 2694.5 IMA of Louisiana Commercial PPO 2862.9 percent of total billed charges 1300 2862.9 Reimbursement at 85% of billed charges DESTR PARAVERTEBRL NERVE C/T 64635 CPT 360 RC outpatient 3368.12 2694.5 Aetna Commercial PPO 1300 fee schedule 1300 2862.9 Case Rate CARPAL TUNNEL SURGERY 64721 CPT 360 RC inpatient 3784.68 1892.34 BCBS Louisiana PPO 1892.34 percent of total billed charges 1892.34 3216.98 50% of Eligible Charges CARPAL TUNNEL SURGERY 64721 CPT 360 RC outpatient 3784.68 3027.74 BCBS Louisiana PPO 3027.74 percent of total billed charges 1300 3216.98 80% of billed charges CARPAL TUNNEL SURGERY 64721 CPT 360 RC outpatient 3784.68 3027.74 Cigna Commercial PPO 2081.57 percent of total billed charges 1300 3216.98 55% of Billed Charges CARPAL TUNNEL SURGERY 64721 CPT 360 RC inpatient 3784.68 1892.34 IMA of Louisiana Commercial PPO 3216.98 percent of total billed charges 1892.34 3216.98 Inpatient Reimbursement at 85% of Billed Charges CARPAL TUNNEL SURGERY 64721 CPT 360 RC outpatient 3784.68 3027.74 IMA of Louisiana Commercial PPO 3216.98 percent of total billed charges 1300 3216.98 Reimbursement at 85% of billed charges CARPAL TUNNEL SURGERY 64721 CPT 360 RC outpatient 3784.68 3027.74 Aetna Commercial PPO 1300 fee schedule 1300 3216.98 Case Rate INTERNAL NERVE REVISION 64727 CPT 360 RC inpatient 3952.93 1976.47 BCBS Louisiana PPO 1976.47 percent of total billed charges 1976.47 3359.99 50% of Eligible Charges INTERNAL NERVE REVISION 64727 CPT 360 RC outpatient 3952.93 3162.34 BCBS Louisiana PPO 3162.34 percent of total billed charges 1300 3359.99 80% of billed charges INTERNAL NERVE REVISION 64727 CPT 360 RC outpatient 3952.93 3162.34 Cigna Commercial PPO 2174.11 percent of total billed charges 1300 3359.99 55% of Billed Charges INTERNAL NERVE REVISION 64727 CPT 360 RC inpatient 3952.93 1976.47 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1976.47 3359.99 Inpatient Reimbursement at 85% of Billed Charges INTERNAL NERVE REVISION 64727 CPT 360 RC outpatient 3952.93 3162.34 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1300 3359.99 Reimbursement at 85% of billed charges INTERNAL NERVE REVISION 64727 CPT 360 RC outpatient 3952.93 3162.34 Aetna Commercial PPO 1300 fee schedule 1300 3359.99 Case Rate REMOVE LIMB NERVE LESION 64782 CPT 360 RC inpatient 3422.33 1711.17 BCBS Louisiana PPO 1711.17 percent of total billed charges 1711.17 2908.98 50% of Eligible Charges REMOVE LIMB NERVE LESION 64782 CPT 360 RC outpatient 3422.33 2737.86 BCBS Louisiana PPO 2737.86 percent of total billed charges 1300 2908.98 80% of billed charges REMOVE LIMB NERVE LESION 64782 CPT 360 RC outpatient 3422.33 2737.86 Cigna Commercial PPO 1882.28 percent of total billed charges 1300 2908.98 55% of Billed Charges REMOVE LIMB NERVE LESION 64782 CPT 360 RC inpatient 3422.33 1711.17 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1711.17 2908.98 Inpatient Reimbursement at 85% of Billed Charges REMOVE LIMB NERVE LESION 64782 CPT 360 RC outpatient 3422.33 2737.86 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1300 2908.98 Reimbursement at 85% of billed charges REMOVE LIMB NERVE LESION 64782 CPT 360 RC outpatient 3422.33 2737.86 Aetna Commercial PPO 1300 fee schedule 1300 2908.98 Case Rate IMPLANT NERVE END 64787 CPT 360 RC inpatient 3952.93 1976.47 BCBS Louisiana PPO 1976.47 percent of total billed charges 1976.47 3359.99 50% of Eligible Charges IMPLANT NERVE END 64787 CPT 360 RC outpatient 3952.93 3162.34 BCBS Louisiana PPO 3162.34 percent of total billed charges 1300 3359.99 80% of billed charges IMPLANT NERVE END 64787 CPT 360 RC outpatient 3952.93 3162.34 Cigna Commercial PPO 2174.11 percent of total billed charges 1300 3359.99 55% of Billed Charges IMPLANT NERVE END 64787 CPT 360 RC inpatient 3952.93 1976.47 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1976.47 3359.99 Inpatient Reimbursement at 85% of Billed Charges IMPLANT NERVE END 64787 CPT 360 RC outpatient 3952.93 3162.34 IMA of Louisiana Commercial PPO 3359.99 percent of total billed charges 1300 3359.99 Reimbursement at 85% of billed charges IMPLANT NERVE END 64787 CPT 360 RC outpatient 3952.93 3162.34 Aetna Commercial PPO 1300 fee schedule 1300 3359.99 Case Rate EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC inpatient 3422.33 1711.17 BCBS Louisiana PPO 1711.17 percent of total billed charges 1711.17 2908.98 50% of Eligible Charges EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC outpatient 3422.33 2737.86 BCBS Louisiana PPO 2737.86 percent of total billed charges 1300 2908.98 80% of billed charges EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC outpatient 3422.33 2737.86 Cigna Commercial PPO 1882.28 percent of total billed charges 1300 2908.98 55% of Billed Charges EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC inpatient 3422.33 1711.17 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1711.17 2908.98 Inpatient Reimbursement at 85% of Billed Charges EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC outpatient 3422.33 2737.86 IMA of Louisiana Commercial PPO 2908.98 percent of total billed charges 1300 2908.98 Reimbursement at 85% of billed charges EXC NEUROFIBROMA NEUROLEMMOMA CUTAN NRV 64788 CPT 360 RC outpatient 3422.33 2737.86 Aetna Commercial PPO 1300 fee schedule 1300 2908.98 Case Rate REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC inpatient 7198.45 3599.23 BCBS Louisiana PPO 3599.23 percent of total billed charges 3599.23 6118.68 50% of Eligible Charges REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC outpatient 7198.45 5758.76 BCBS Louisiana PPO 5758.76 percent of total billed charges 100 6118.68 80% of billed charges REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC outpatient 7198.45 5758.76 Cigna Commercial PPO 3959.15 percent of total billed charges 100 6118.68 55% of Billed Charges REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC inpatient 7198.45 3599.23 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 3599.23 6118.68 Inpatient Reimbursement at 85% of Billed Charges REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC outpatient 7198.45 5758.76 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 100 6118.68 Reimbursement at 85% of billed charges REPAIR OF DURAL CEREBROSPINAL FLUID LEAK 63709 CPT 360 RC outpatient 7198.45 5758.76 Aetna Commercial PPO 100 fee schedule 100 6118.68 Case Rate RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges RELIEVE PRESSURE ON NERVE OR NERVES 64722 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC inpatient 4430.75 2215.38 BCBS Louisiana PPO 2215.38 percent of total billed charges 2215.38 3766.14 50% of Eligible Charges SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC outpatient 4430.75 3544.6 BCBS Louisiana PPO 3544.6 percent of total billed charges 1300 3766.14 80% of billed charges SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC outpatient 4430.75 3544.6 Cigna Commercial PPO 2436.91 percent of total billed charges 1300 3766.14 55% of Billed Charges SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC inpatient 4430.75 2215.38 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 2215.38 3766.14 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC outpatient 4430.75 3544.6 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 1300 3766.14 Reimbursement at 85% of billed charges SHOULDER ARTHROSCOPY WITH EXT DEBRIDEMEN 29823 CPT 360 RC outpatient 4430.75 3544.6 Aetna Commercial PPO 1300 fee schedule 1300 3766.14 Case Rate LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC inpatient 30767.9 15383.95 BCBS Louisiana PPO 15383.95 percent of total billed charges 15383.95 26152.72 50% of Eligible Charges LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC outpatient 30767.9 24614.32 BCBS Louisiana PPO 24614.32 percent of total billed charges 1300 26152.72 80% of billed charges LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC outpatient 30767.9 24614.32 Cigna Commercial PPO 6800 case rate 1300 26152.72 6800 case rate LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC inpatient 30767.9 15383.95 IMA of Louisiana Commercial PPO 26152.72 percent of total billed charges 15383.95 26152.72 Inpatient Reimbursement at 85% of Billed Charges LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC outpatient 30767.9 24614.32 IMA of Louisiana Commercial PPO 26152.72 percent of total billed charges 1300 26152.72 Reimbursement at 85% of billed charges LAMINECTOMY FOR IMPLANTATION OF NEUROSTI 63655 CPT 360 RC outpatient 30767.9 24614.32 Aetna Commercial PPO 1300 fee schedule 1300 26152.72 Case Rate PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC inpatient 1432.13 716.07 BCBS Louisiana PPO 716.07 percent of total billed charges 716.07 1217.31 50% of Eligible Charges PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC outpatient 1432.13 1145.7 BCBS Louisiana PPO 1145.7 percent of total billed charges 787.67 1300 80% of billed charges PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC outpatient 1432.13 1145.7 Cigna Commercial PPO 787.67 percent of total billed charges 787.67 1300 55% of Billed Charges PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC inpatient 1432.13 716.07 IMA of Louisiana Commercial PPO 1217.31 percent of total billed charges 716.07 1217.31 Inpatient Reimbursement at 85% of Billed Charges PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC outpatient 1432.13 1145.7 IMA of Louisiana Commercial PPO 1217.31 percent of total billed charges 787.67 1300 Reimbursement at 85% of billed charges PERCUTANEOUS ASPIRATION WITHIN NUCLEUS 62267 CPT 360 RC outpatient 1432.13 1145.7 Aetna Commercial PPO 1300 fee schedule 787.67 1300 Case Rate VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 100 11913.64 55% of Billed Charges VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges VERTEBRAL CORPECTOMY PARTIAL OR COMPLETE 63081 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC inpatient 6841.23 3420.62 BCBS Louisiana PPO 3420.62 percent of total billed charges 3420.62 5815.05 50% of Eligible Charges REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC outpatient 6841.23 5472.98 BCBS Louisiana PPO 5472.98 percent of total billed charges 1300 5815.05 80% of billed charges REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC outpatient 6841.23 5472.98 Cigna Commercial PPO 3762.68 percent of total billed charges 1300 5815.05 55% of Billed Charges REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC inpatient 6841.23 3420.62 IMA of Louisiana Commercial PPO 5815.05 percent of total billed charges 3420.62 5815.05 Inpatient Reimbursement at 85% of Billed Charges REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC outpatient 6841.23 5472.98 IMA of Louisiana Commercial PPO 5815.05 percent of total billed charges 1300 5815.05 Reimbursement at 85% of billed charges REPAIR INITIAL INCISIONAL/VENTRAL HERNIA 49560 CPT 360 RC outpatient 6841.23 5472.98 Aetna Commercial PPO 1300 fee schedule 1300 5815.05 Case Rate LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 100 11913.64 55% of Billed Charges LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges LAMINOPLASTY CERVICAL WITH DECOMPRESSION 63051 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC inpatient 2975.88 1487.94 BCBS Louisiana PPO 1487.94 percent of total billed charges 1487.94 2529.5 50% of Eligible Charges HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC outpatient 2975.88 2380.7 BCBS Louisiana PPO 2380.7 percent of total billed charges 1300 2529.5 80% of billed charges HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC outpatient 2975.88 2380.7 Cigna Commercial PPO 1636.73 percent of total billed charges 1300 2529.5 55% of Billed Charges HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC inpatient 2975.88 1487.94 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1487.94 2529.5 Inpatient Reimbursement at 85% of Billed Charges HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC outpatient 2975.88 2380.7 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1300 2529.5 Reimbursement at 85% of billed charges HIP ARTHROSCOPY W/REMOVAL OF FOREIGN BOD 29861 CPT 360 RC outpatient 2975.88 2380.7 Aetna Commercial PPO 1300 fee schedule 1300 2529.5 Case Rate HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC inpatient 13175.08 6587.54 BCBS Louisiana PPO 6587.54 percent of total billed charges 6587.54 11198.82 50% of Eligible Charges HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC outpatient 13175.08 10540.06 BCBS Louisiana PPO 10540.06 percent of total billed charges 1300 11198.82 80% of billed charges HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC outpatient 13175.08 10540.06 Cigna Commercial PPO 7246.29 percent of total billed charges 1300 11198.82 55% of Billed Charges HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC inpatient 13175.08 6587.54 IMA of Louisiana Commercial PPO 11198.82 percent of total billed charges 6587.54 11198.82 Inpatient Reimbursement at 85% of Billed Charges HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC outpatient 13175.08 10540.06 IMA of Louisiana Commercial PPO 11198.82 percent of total billed charges 1300 11198.82 Reimbursement at 85% of billed charges HIP ARTHROSCOPY W/DEBRIDEMENT OF ARTICUL 29862 CPT 360 RC outpatient 13175.08 10540.06 Aetna Commercial PPO 1300 fee schedule 1300 11198.82 Case Rate KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC inpatient 10249.52 5124.76 BCBS Louisiana PPO 5124.76 percent of total billed charges 5124.76 8712.09 50% of Eligible Charges KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC outpatient 10249.52 8199.62 BCBS Louisiana PPO 8199.62 percent of total billed charges 1300 8712.09 80% of billed charges KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC outpatient 10249.52 8199.62 Cigna Commercial PPO 5637.24 percent of total billed charges 1300 8712.09 55% of Billed Charges KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC inpatient 10249.52 5124.76 IMA of Louisiana Commercial PPO 8712.09 percent of total billed charges 5124.76 8712.09 Inpatient Reimbursement at 85% of Billed Charges KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC outpatient 10249.52 8199.62 IMA of Louisiana Commercial PPO 8712.09 percent of total billed charges 1300 8712.09 Reimbursement at 85% of billed charges KNEE ARTHROSCOPY SURGICAL DEBRIDEMENT 29877 CPT 360 RC outpatient 10249.52 8199.62 Aetna Commercial PPO 1300 fee schedule 1300 8712.09 Case Rate ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC inpatient 5621.13 2810.57 BCBS Louisiana PPO 2810.57 percent of total billed charges 2810.57 4777.96 50% of Eligible Charges ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC outpatient 5621.13 4496.9 BCBS Louisiana PPO 4496.9 percent of total billed charges 1300 4777.96 80% of billed charges ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC outpatient 5621.13 4496.9 Cigna Commercial PPO 3091.62 percent of total billed charges 1300 4777.96 55% of Billed Charges ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC inpatient 5621.13 2810.57 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 2810.57 4777.96 Inpatient Reimbursement at 85% of Billed Charges ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC outpatient 5621.13 4496.9 IMA of Louisiana Commercial PPO 4777.96 percent of total billed charges 1300 4777.96 Reimbursement at 85% of billed charges ARTHRS WRST EXC RPR TRIANG FIBROCART 29846 CPT 360 RC outpatient 5621.13 4496.9 Aetna Commercial PPO 1300 fee schedule 1300 4777.96 Case Rate WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges WRIST ARTHROSCOPY SX SYNOVECTOMEY PARTIA 29844 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC inpatient 1811.83 905.92 BCBS Louisiana PPO 905.92 percent of total billed charges 905.92 1540.06 50% of Eligible Charges SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC outpatient 1811.83 1449.46 BCBS Louisiana PPO 1449.46 percent of total billed charges 100 1540.06 80% of billed charges SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC outpatient 1811.83 1449.46 Cigna Commercial PPO 996.51 percent of total billed charges 100 1540.06 55% of Billed Charges SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC inpatient 1811.83 905.92 IMA of Louisiana Commercial PPO 1540.06 percent of total billed charges 905.92 1540.06 Inpatient Reimbursement at 85% of Billed Charges SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC outpatient 1811.83 1449.46 IMA of Louisiana Commercial PPO 1540.06 percent of total billed charges 100 1540.06 Reimbursement at 85% of billed charges SYMPTH DGTAL ARTS EA DGT 64820 CPT 360 RC outpatient 1811.83 1449.46 Aetna Commercial PPO 100 fee schedule 100 1540.06 Case Rate NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges NERVE REPAIR W/CONDUIT EA NERVE 64910 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges DST NROLYTC AGNT PARVERTEB IM/SAC 64635 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges NJX ANES CELIAC ;E +- RAD MNTR 64530 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC inpatient 41102 20551 BCBS Louisiana PPO 20551 percent of total billed charges 20551 34936.7 50% of Eligible Charges IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC outpatient 41102 32881.6 BCBS Louisiana PPO 32881.6 percent of total billed charges 1300 34936.7 80% of billed charges IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC outpatient 41102 32881.6 Cigna Commercial PPO 22606.1 percent of total billed charges 1300 34936.7 55% of Billed Charges IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC inpatient 41102 20551 IMA of Louisiana Commercial PPO 34936.7 percent of total billed charges 20551 34936.7 Inpatient Reimbursement at 85% of Billed Charges IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC outpatient 41102 32881.6 IMA of Louisiana Commercial PPO 34936.7 percent of total billed charges 1300 34936.7 Reimbursement at 85% of billed charges IMPLTJ/RPL ITHCL/EDRL DRUG NFS SUBQ RSVR 62360 CPT 360 RC outpatient 41102 32881.6 Aetna Commercial PPO 1300 fee schedule 1300 34936.7 Case Rate ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC inpatient 11913.65 5956.83 BCBS Louisiana PPO 5956.83 percent of total billed charges 5956.83 10126.6 50% of Eligible Charges ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC outpatient 11913.65 9530.92 BCBS Louisiana PPO 9530.92 percent of total billed charges 1300 10126.6 80% of billed charges ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC outpatient 11913.65 9530.92 Cigna Commercial PPO 6552.51 percent of total billed charges 1300 10126.6 55% of Billed Charges ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC inpatient 11913.65 5956.83 IMA of Louisiana Commercial PPO 10126.6 percent of total billed charges 5956.83 10126.6 Inpatient Reimbursement at 85% of Billed Charges ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC outpatient 11913.65 9530.92 IMA of Louisiana Commercial PPO 10126.6 percent of total billed charges 1300 10126.6 Reimbursement at 85% of billed charges ARTHRS AID TIBIAL FRACTURE PROXIMAL UNIC 29855 CPT 360 RC outpatient 11913.65 9530.92 Aetna Commercial PPO 1300 fee schedule 1300 10126.6 Case Rate PT STERILE WHIRLPOOL 97022 CPT 421 RC inpatient 47.75 23.88 BCBS Louisiana PPO 23.88 percent of total billed charges 23.88 40.59 50% of Eligible Charges PT STERILE WHIRLPOOL 97022 CPT 421 RC outpatient 47.75 38.2 BCBS Louisiana PPO 38.2 percent of total billed charges 38.2 85 80% of billed charge PT STERILE WHIRLPOOL 97022 CPT 421 RC outpatient 47.75 38.2 Cigna Commercial PPO 85 other 38.2 85 63% of Billed Charges PT STERILE WHIRLPOOL 97022 CPT 421 RC inpatient 47.75 23.88 IMA of Louisiana Commercial PPO 40.59 percent of total billed charges 23.88 40.59 Inpatient Reimbursement at 85% of Billed Charges PT STERILE WHIRLPOOL 97022 CPT 421 RC outpatient 47.75 38.2 IMA of Louisiana Commercial PPO 40.59 percent of total billed charges 38.2 85 Reimbursement at 85% of billed charges PT STERILE WHIRLPOOL 97022 CPT 421 RC outpatient 47.75 38.2 Aetna Commercial PPO 43.52 fee schedule 38.2 85 200% Of Aetna Market Fee Schedule ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC inpatient 24801.15 12400.58 BCBS Louisiana PPO 12400.58 percent of total billed charges 12400.58 21080.98 50% of Eligible Charges ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC outpatient 24801.15 19840.92 BCBS Louisiana PPO 19840.92 percent of total billed charges 1300 21080.98 80% of billed charges ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC outpatient 24801.15 19840.92 Cigna Commercial PPO 13640.63 percent of total billed charges 1300 21080.98 55% of Billed Charges ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC inpatient 24801.15 12400.58 IMA of Louisiana Commercial PPO 21080.98 percent of total billed charges 12400.58 21080.98 Inpatient Reimbursement at 85% of Billed Charges ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC outpatient 24801.15 19840.92 IMA of Louisiana Commercial PPO 21080.98 percent of total billed charges 1300 21080.98 Reimbursement at 85% of billed charges ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNT 29889 CPT 360 RC outpatient 24801.15 19840.92 Aetna Commercial PPO 1300 fee schedule 1300 21080.98 Case Rate EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC inpatient 5534.1 2767.05 BCBS Louisiana PPO 2767.05 percent of total billed charges 2767.05 4703.99 50% of Eligible Charges EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC outpatient 5534.1 4427.28 BCBS Louisiana PPO 4427.28 percent of total billed charges 1300 4703.99 80% of billed charges EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC outpatient 5534.1 4427.28 Cigna Commercial PPO 3043.76 percent of total billed charges 1300 4703.99 55% of Billed Charges EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC inpatient 5534.1 2767.05 IMA of Louisiana Commercial PPO 4703.99 percent of total billed charges 2767.05 4703.99 Inpatient Reimbursement at 85% of Billed Charges EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC outpatient 5534.1 4427.28 IMA of Louisiana Commercial PPO 4703.99 percent of total billed charges 1300 4703.99 Reimbursement at 85% of billed charges EXC NEUROMA HD/FT EA NRV XCP SM DGT 64783 CPT 360 RC outpatient 5534.1 4427.28 Aetna Commercial PPO 1300 fee schedule 1300 4703.99 Case Rate BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC inpatient 5796.65 2898.33 BCBS Louisiana PPO 2898.33 percent of total billed charges 2898.33 4927.15 50% of Eligible Charges BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC outpatient 5796.65 4637.32 BCBS Louisiana PPO 4637.32 percent of total billed charges 1300 4927.15 80% of billed charges BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC outpatient 5796.65 4637.32 Cigna Commercial PPO 3188.16 percent of total billed charges 1300 4927.15 55% of Billed Charges BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC inpatient 5796.65 2898.33 IMA of Louisiana Commercial PPO 4927.15 percent of total billed charges 2898.33 4927.15 Inpatient Reimbursement at 85% of Billed Charges BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC outpatient 5796.65 4637.32 IMA of Louisiana Commercial PPO 4927.15 percent of total billed charges 1300 4927.15 Reimbursement at 85% of billed charges BX/EXC LYMPH NODE OPN SUPFC 38500 CPT 360 RC outpatient 5796.65 4637.32 Aetna Commercial PPO 1300 fee schedule 1300 4927.15 Case Rate REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC inpatient 14230.68 7115.34 BCBS Louisiana PPO 7115.34 percent of total billed charges 7115.34 12096.08 50% of Eligible Charges REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC outpatient 14230.68 11384.54 BCBS Louisiana PPO 11384.54 percent of total billed charges 1300 12096.08 80% of billed charges REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC outpatient 14230.68 11384.54 Cigna Commercial PPO 7826.87 percent of total billed charges 1300 12096.08 55% of Billed Charges REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC inpatient 14230.68 7115.34 IMA of Louisiana Commercial PPO 12096.08 percent of total billed charges 7115.34 12096.08 Inpatient Reimbursement at 85% of Billed Charges REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC outpatient 14230.68 11384.54 IMA of Louisiana Commercial PPO 12096.08 percent of total billed charges 1300 12096.08 Reimbursement at 85% of billed charges REVISE/REMOVE NEURORECEIVER 61888 CPT 360 RC outpatient 14230.68 11384.54 Aetna Commercial PPO 1300 fee schedule 1300 12096.08 Case Rate NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges NJX INTERLAMINAR LMBR/SAC 62323 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges ELBOW ARTHROSCOPY/SURGERY 29837 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate excision laminectory other herniated dis 63271 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges excision laminectory other herniated dis 63271 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges excision laminectory other herniated dis 63271 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 100 11913.64 6800 case rate excision laminectory other herniated dis 63271 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges excision laminectory other herniated dis 63271 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges excision laminectory other herniated dis 63271 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 100 11913.64 55% of Billed Charges ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges ANTERIOR CERVICAL ARTHRODESIS 63091 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT FOOT 2 VIEWS 73620 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC inpatient 530 265 BCBS Louisiana PPO 265 percent of total billed charges 265 450.5 50% of Eligible Charges XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 BCBS Louisiana PPO 424 percent of total billed charges 291.5 450.5 80% of billed charge XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 Cigna Commercial PPO 291.5 percent of total billed charges 291.5 450.5 55% of Billed Charges XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC inpatient 530 265 IMA of Louisiana Commercial PPO 450.5 percent of total billed charges 265 450.5 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 IMA of Louisiana Commercial PPO 450.5 percent of total billed charges 291.5 450.5 Reimbursement at 85% of billed charges XRAY DX LT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 Aetna Commercial PPO 291.5 percent of total billed charges 291.5 450.5 55 of billed Charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC inpatient 90.45 45.23 BCBS Louisiana PPO 45.23 percent of total billed charges 45.23 76.88 50% of Eligible Charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC outpatient 90.45 63.32 BCBS Louisiana PPO 63.32 percent of total billed charges 49.75 700 70% of billed charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC outpatient 90.45 63.32 Cigna Commercial PPO 49.75 percent of total billed charges 49.75 700 55% of Billed Charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC inpatient 90.45 45.23 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 45.23 76.88 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC outpatient 90.45 63.32 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 49.75 700 Reimbursement at 85% of billed charges XRAY DX LT WRIST AP&LAT 73100 CPT 320 RC outpatient 90.45 63.32 Aetna Commercial PPO 700 case rate 49.75 700 700 Per Code Per DOS Paid In Addition MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI UPPER JOINT EXTREMITY 73221 CPT 619 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges CT OF ABDOMEN WITHOUT CONTRAST 74150 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC inpatient 145 72.5 BCBS Louisiana PPO 72.5 percent of total billed charges 72.5 123.25 50% of Eligible Charges XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC outpatient 145 116 BCBS Louisiana PPO 116 percent of total billed charges 79.75 123.25 80% of billed charge XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC outpatient 145 116 Cigna Commercial PPO 79.75 percent of total billed charges 79.75 123.25 55% of Billed Charges XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC inpatient 145 72.5 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 72.5 123.25 Inpatient Reimbursement at 85% of Billed Charges XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC outpatient 145 116 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 79.75 123.25 Reimbursement at 85% of billed charges XRAY ABDOMEN AP - PROFESSIONAL 74000 CPT 972 RC outpatient 145 116 Aetna Commercial PPO 79.75 percent of total billed charges 79.75 123.25 55 of billed Charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges US EXTREMITY NON-VASC REAL-TIME IMG COMP 76881 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC inpatient 326 163 BCBS Louisiana PPO 163 percent of total billed charges 163 277.1 50% of Eligible Charges US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC outpatient 326 228.2 BCBS Louisiana PPO 228.2 percent of total billed charges 179.3 700 70% of billed charges US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC outpatient 326 228.2 Cigna Commercial PPO 179.3 percent of total billed charges 179.3 700 55% of Billed Charges US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC inpatient 326 163 IMA of Louisiana Commercial PPO 277.1 percent of total billed charges 163 277.1 Inpatient Reimbursement at 85% of Billed Charges US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC outpatient 326 228.2 IMA of Louisiana Commercial PPO 277.1 percent of total billed charges 179.3 700 Reimbursement at 85% of billed charges US EXTREMITY NON-VASC REAL-TIME IMG LMTD 76882 CPT 320 RC outpatient 326 228.2 Aetna Commercial PPO 700 case rate 179.3 700 700 Per Code Per DOS Paid In Addition CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT RIGHT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT LEFT LOWER EXTREMITY W/CONTRAST 73701 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC inpatient 422.38 211.19 BCBS Louisiana PPO 211.19 percent of total billed charges 211.19 359.02 50% of Eligible Charges PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC outpatient 422.38 337.9 BCBS Louisiana PPO 337.9 percent of total billed charges 85 359.02 80% of billed charge PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC outpatient 422.38 337.9 Cigna Commercial PPO 85 other 85 359.02 63% of Billed Charges PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC inpatient 422.38 211.19 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 211.19 359.02 Inpatient Reimbursement at 85% of Billed Charges PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC outpatient 422.38 337.9 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 85 359.02 Reimbursement at 85% of billed charges PT EQUAL TO 20 SQUARE CENTIMETERS 97597 CPT 421 RC outpatient 422.38 337.9 Aetna Commercial PPO 232.31 percent of total billed charges 85 359.02 55 of billed Charges PT PT 15 MIN EVALUATI 97001 CPT 424 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges PT PT 15 MIN EVALUATI 97001 CPT 424 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 85 148.75 80% of billed charge PT PT 15 MIN EVALUATI 97001 CPT 424 RC outpatient 175 140 Cigna Commercial PPO 85 other 85 148.75 63% of Billed Charges PT PT 15 MIN EVALUATI 97001 CPT 424 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges PT PT 15 MIN EVALUATI 97001 CPT 424 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 85 148.75 Reimbursement at 85% of billed charges PT PT 15 MIN EVALUATI 97001 CPT 424 RC outpatient 175 140 Aetna Commercial PPO 96.25 percent of total billed charges 85 148.75 55 of billed Charges PT PT 15 MIN EXERCISE 97110 CPT 421 RC inpatient 29.86 14.93 BCBS Louisiana PPO 14.93 percent of total billed charges 14.93 25.38 50% of Eligible Charges PT PT 15 MIN EXERCISE 97110 CPT 421 RC outpatient 29.86 23.89 BCBS Louisiana PPO 23.89 percent of total billed charges 23.89 85 80% of billed charge PT PT 15 MIN EXERCISE 97110 CPT 421 RC outpatient 29.86 23.89 Cigna Commercial PPO 85 other 23.89 85 63% of Billed Charges PT PT 15 MIN EXERCISE 97110 CPT 421 RC inpatient 29.86 14.93 IMA of Louisiana Commercial PPO 25.38 percent of total billed charges 14.93 25.38 Inpatient Reimbursement at 85% of Billed Charges PT PT 15 MIN EXERCISE 97110 CPT 421 RC outpatient 29.86 23.89 IMA of Louisiana Commercial PPO 25.38 percent of total billed charges 23.89 85 Reimbursement at 85% of billed charges PT PT 15 MIN EXERCISE 97110 CPT 421 RC outpatient 29.86 23.89 Aetna Commercial PPO 61.9 fee schedule 23.89 85 200% Of Aetna Market Fee Schedule PT PT PATIENT EDUCATION 97116 CPT 421 RC inpatient 26.19 13.1 BCBS Louisiana PPO 13.1 percent of total billed charges 13.1 22.26 50% of Eligible Charges PT PT PATIENT EDUCATION 97116 CPT 421 RC outpatient 26.19 20.95 BCBS Louisiana PPO 20.95 percent of total billed charges 20.95 85 80% of billed charge PT PT PATIENT EDUCATION 97116 CPT 421 RC outpatient 26.19 20.95 Cigna Commercial PPO 85 other 20.95 85 63% of Billed Charges PT PT PATIENT EDUCATION 97116 CPT 421 RC inpatient 26.19 13.1 IMA of Louisiana Commercial PPO 22.26 percent of total billed charges 13.1 22.26 Inpatient Reimbursement at 85% of Billed Charges PT PT PATIENT EDUCATION 97116 CPT 421 RC outpatient 26.19 20.95 IMA of Louisiana Commercial PPO 22.26 percent of total billed charges 20.95 85 Reimbursement at 85% of billed charges PT PT PATIENT EDUCATION 97116 CPT 421 RC outpatient 26.19 20.95 Aetna Commercial PPO 54.28 fee schedule 20.95 85 200% Of Aetna Market Fee Schedule PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC inpatient 17.52 8.76 BCBS Louisiana PPO 8.76 percent of total billed charges 8.76 14.89 50% of Eligible Charges PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC outpatient 17.52 14.02 BCBS Louisiana PPO 14.02 percent of total billed charges 14.02 400 80% of billed charge PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC outpatient 17.52 14.02 Cigna Commercial PPO 85 other 14.02 400 63% of Billed Charges PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC inpatient 17.52 8.76 IMA of Louisiana Commercial PPO 14.89 percent of total billed charges 8.76 14.89 Inpatient Reimbursement at 85% of Billed Charges PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC outpatient 17.52 14.02 IMA of Louisiana Commercial PPO 14.89 percent of total billed charges 14.02 400 Reimbursement at 85% of billed charges PT UNLISTED THERAPEUTIC PROCEDURE 97139 CPT 421 RC outpatient 17.52 14.02 Aetna Commercial PPO 400 fee schedule 14.02 400 200% Of Aetna Market Fee Schedule PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC inpatient 49.95 24.98 BCBS Louisiana PPO 24.98 percent of total billed charges 24.98 42.46 50% of Eligible Charges PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC outpatient 49.95 39.96 BCBS Louisiana PPO 39.96 percent of total billed charges 35.98 85 80% of billed charge PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC outpatient 49.95 39.96 Cigna Commercial PPO 85 other 35.98 85 63% of Billed Charges PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC inpatient 49.95 24.98 IMA of Louisiana Commercial PPO 42.46 percent of total billed charges 24.98 42.46 Inpatient Reimbursement at 85% of Billed Charges PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC outpatient 49.95 39.96 IMA of Louisiana Commercial PPO 42.46 percent of total billed charges 35.98 85 Reimbursement at 85% of billed charges PT VASOPNEUMATIC DEVICES 97016 CPT 421 RC outpatient 49.95 39.96 Aetna Commercial PPO 35.98 fee schedule 35.98 85 200% Of Aetna Market Fee Schedule ACL KIT 272 RC inpatient 937.5 468.75 BCBS Louisiana PPO 468.75 percent of total billed charges 468.75 796.88 50% of Eligible Charges ACL KIT 272 RC outpatient 937.5 750 BCBS Louisiana PPO 750 percent of total billed charges 515.63 796.88 80% of billed charge ACL KIT 272 RC outpatient 937.5 750 Cigna Commercial PPO 515.63 percent of total billed charges 515.63 796.88 55% of Billed Charges ACL KIT 272 RC inpatient 937.5 468.75 IMA of Louisiana Commercial PPO 796.88 percent of total billed charges 468.75 796.88 Inpatient Reimbursement at 85% of Billed Charges ACL KIT 272 RC outpatient 937.5 750 IMA of Louisiana Commercial PPO 796.88 percent of total billed charges 515.63 796.88 Reimbursement at 85% of billed charges ACL KIT 272 RC outpatient 937.5 750 Aetna Commercial PPO 515.63 percent of total billed charges 515.63 796.88 55 of billed Charges AIRWAY BERMAN 100MM 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges AIRWAY BERMAN 100MM 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge AIRWAY BERMAN 100MM 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges AIRWAY BERMAN 100MM 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges AIRWAY BERMAN 100MM 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges AIRWAY BERMAN 100MM 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges KERRISON TUBING PNEUMATIC 272 RC inpatient 2164.44 1082.22 BCBS Louisiana PPO 1082.22 percent of total billed charges 1082.22 1839.77 50% of Eligible Charges KERRISON TUBING PNEUMATIC 272 RC outpatient 2164.44 1731.55 BCBS Louisiana PPO 1731.55 percent of total billed charges 1190.44 1839.77 80% of billed charge KERRISON TUBING PNEUMATIC 272 RC outpatient 2164.44 1731.55 Cigna Commercial PPO 1190.44 percent of total billed charges 1190.44 1839.77 55% of Billed Charges KERRISON TUBING PNEUMATIC 272 RC inpatient 2164.44 1082.22 IMA of Louisiana Commercial PPO 1839.77 percent of total billed charges 1082.22 1839.77 Inpatient Reimbursement at 85% of Billed Charges KERRISON TUBING PNEUMATIC 272 RC outpatient 2164.44 1731.55 IMA of Louisiana Commercial PPO 1839.77 percent of total billed charges 1190.44 1839.77 Reimbursement at 85% of billed charges KERRISON TUBING PNEUMATIC 272 RC outpatient 2164.44 1731.55 Aetna Commercial PPO 1190.44 percent of total billed charges 1190.44 1839.77 55 of billed Charges STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC inpatient 280 140 BCBS Louisiana PPO 140 percent of total billed charges 140 238 50% of Eligible Charges STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 BCBS Louisiana PPO 224 percent of total billed charges 154 238 80% of billed charge STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 Cigna Commercial PPO 154 percent of total billed charges 154 238 55% of Billed Charges STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC inpatient 280 140 IMA of Louisiana Commercial PPO 238 percent of total billed charges 140 238 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 IMA of Louisiana Commercial PPO 238 percent of total billed charges 154 238 Reimbursement at 85% of billed charges STEINMAN PIN 4.0MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 Aetna Commercial PPO 154 percent of total billed charges 154 238 55 of billed Charges BEDPAN FRACTURE 270 RC inpatient 253.26 126.63 BCBS Louisiana PPO 126.63 percent of total billed charges 126.63 215.27 50% of Eligible Charges BEDPAN FRACTURE 270 RC outpatient 253.26 202.61 BCBS Louisiana PPO 202.61 percent of total billed charges 139.29 215.27 80% of billed charge BEDPAN FRACTURE 270 RC outpatient 253.26 202.61 Cigna Commercial PPO 139.29 percent of total billed charges 139.29 215.27 55% of Billed Charges BEDPAN FRACTURE 270 RC inpatient 253.26 126.63 IMA of Louisiana Commercial PPO 215.27 percent of total billed charges 126.63 215.27 Inpatient Reimbursement at 85% of Billed Charges BEDPAN FRACTURE 270 RC outpatient 253.26 202.61 IMA of Louisiana Commercial PPO 215.27 percent of total billed charges 139.29 215.27 Reimbursement at 85% of billed charges BEDPAN FRACTURE 270 RC outpatient 253.26 202.61 Aetna Commercial PPO 139.29 percent of total billed charges 139.29 215.27 55 of billed Charges BLADE SURG 11 CARBON 272 RC inpatient 115.7 57.85 BCBS Louisiana PPO 57.85 percent of total billed charges 57.85 98.35 50% of Eligible Charges BLADE SURG 11 CARBON 272 RC outpatient 115.7 92.56 BCBS Louisiana PPO 92.56 percent of total billed charges 63.64 98.35 80% of billed charge BLADE SURG 11 CARBON 272 RC outpatient 115.7 92.56 Cigna Commercial PPO 63.64 percent of total billed charges 63.64 98.35 55% of Billed Charges BLADE SURG 11 CARBON 272 RC inpatient 115.7 57.85 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 57.85 98.35 Inpatient Reimbursement at 85% of Billed Charges BLADE SURG 11 CARBON 272 RC outpatient 115.7 92.56 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 63.64 98.35 Reimbursement at 85% of billed charges BLADE SURG 11 CARBON 272 RC outpatient 115.7 92.56 Aetna Commercial PPO 63.64 percent of total billed charges 63.64 98.35 55 of billed Charges BLADE SURG 15 CARBON 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges BLADE SURG 15 CARBON 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge BLADE SURG 15 CARBON 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges BLADE SURG 15 CARBON 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges BLADE SURG 15 CARBON 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges BLADE SURG 15 CARBON 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SAW BLADE SP-115 272 RC inpatient 36.04 18.02 BCBS Louisiana PPO 18.02 percent of total billed charges 18.02 30.63 50% of Eligible Charges SAW BLADE SP-115 272 RC outpatient 36.04 28.83 BCBS Louisiana PPO 28.83 percent of total billed charges 19.82 30.63 80% of billed charge SAW BLADE SP-115 272 RC outpatient 36.04 28.83 Cigna Commercial PPO 19.82 percent of total billed charges 19.82 30.63 55% of Billed Charges SAW BLADE SP-115 272 RC inpatient 36.04 18.02 IMA of Louisiana Commercial PPO 30.63 percent of total billed charges 18.02 30.63 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE SP-115 272 RC outpatient 36.04 28.83 IMA of Louisiana Commercial PPO 30.63 percent of total billed charges 19.82 30.63 Reimbursement at 85% of billed charges SAW BLADE SP-115 272 RC outpatient 36.04 28.83 Aetna Commercial PPO 19.82 percent of total billed charges 19.82 30.63 55 of billed Charges BONE WAX W31G 272 RC inpatient 22 11 BCBS Louisiana PPO 11 percent of total billed charges 11 18.7 50% of Eligible Charges BONE WAX W31G 272 RC outpatient 22 17.6 BCBS Louisiana PPO 17.6 percent of total billed charges 12.1 18.7 80% of billed charge BONE WAX W31G 272 RC outpatient 22 17.6 Cigna Commercial PPO 12.1 percent of total billed charges 12.1 18.7 55% of Billed Charges BONE WAX W31G 272 RC inpatient 22 11 IMA of Louisiana Commercial PPO 18.7 percent of total billed charges 11 18.7 Inpatient Reimbursement at 85% of Billed Charges BONE WAX W31G 272 RC outpatient 22 17.6 IMA of Louisiana Commercial PPO 18.7 percent of total billed charges 12.1 18.7 Reimbursement at 85% of billed charges BONE WAX W31G 272 RC outpatient 22 17.6 Aetna Commercial PPO 12.1 percent of total billed charges 12.1 18.7 55 of billed Charges CRUTCH ALUM DRESSED ADULT 270 RC inpatient 65.15 32.58 BCBS Louisiana PPO 32.58 percent of total billed charges 32.58 55.38 50% of Eligible Charges CRUTCH ALUM DRESSED ADULT 270 RC outpatient 65.15 52.12 BCBS Louisiana PPO 52.12 percent of total billed charges 35.83 55.38 80% of billed charge CRUTCH ALUM DRESSED ADULT 270 RC outpatient 65.15 52.12 Cigna Commercial PPO 35.83 percent of total billed charges 35.83 55.38 55% of Billed Charges CRUTCH ALUM DRESSED ADULT 270 RC inpatient 65.15 32.58 IMA of Louisiana Commercial PPO 55.38 percent of total billed charges 32.58 55.38 Inpatient Reimbursement at 85% of Billed Charges CRUTCH ALUM DRESSED ADULT 270 RC outpatient 65.15 52.12 IMA of Louisiana Commercial PPO 55.38 percent of total billed charges 35.83 55.38 Reimbursement at 85% of billed charges CRUTCH ALUM DRESSED ADULT 270 RC outpatient 65.15 52.12 Aetna Commercial PPO 35.83 percent of total billed charges 35.83 55.38 55 of billed Charges TUBING PEDIATRIC IV 272 RC inpatient 12.96 6.48 BCBS Louisiana PPO 6.48 percent of total billed charges 6.48 11.02 50% of Eligible Charges TUBING PEDIATRIC IV 272 RC outpatient 12.96 10.37 BCBS Louisiana PPO 10.37 percent of total billed charges 7.13 11.02 80% of billed charge TUBING PEDIATRIC IV 272 RC outpatient 12.96 10.37 Cigna Commercial PPO 7.13 percent of total billed charges 7.13 11.02 55% of Billed Charges TUBING PEDIATRIC IV 272 RC inpatient 12.96 6.48 IMA of Louisiana Commercial PPO 11.02 percent of total billed charges 6.48 11.02 Inpatient Reimbursement at 85% of Billed Charges TUBING PEDIATRIC IV 272 RC outpatient 12.96 10.37 IMA of Louisiana Commercial PPO 11.02 percent of total billed charges 7.13 11.02 Reimbursement at 85% of billed charges TUBING PEDIATRIC IV 272 RC outpatient 12.96 10.37 Aetna Commercial PPO 7.13 percent of total billed charges 7.13 11.02 55 of billed Charges DRAIN PENROSE STR 1/4 X 12 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges DRAIN PENROSE STR 1/4 X 12 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge DRAIN PENROSE STR 1/4 X 12 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges DRAIN PENROSE STR 1/4 X 12 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges DRAIN PENROSE STR 1/4 X 12 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges DRAIN PENROSE STR 1/4 X 12 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges DRAPE MINI C-ARM 272 RC inpatient 52.28 26.14 BCBS Louisiana PPO 26.14 percent of total billed charges 26.14 44.44 50% of Eligible Charges DRAPE MINI C-ARM 272 RC outpatient 52.28 41.82 BCBS Louisiana PPO 41.82 percent of total billed charges 28.75 44.44 80% of billed charge DRAPE MINI C-ARM 272 RC outpatient 52.28 41.82 Cigna Commercial PPO 28.75 percent of total billed charges 28.75 44.44 55% of Billed Charges DRAPE MINI C-ARM 272 RC inpatient 52.28 26.14 IMA of Louisiana Commercial PPO 44.44 percent of total billed charges 26.14 44.44 Inpatient Reimbursement at 85% of Billed Charges DRAPE MINI C-ARM 272 RC outpatient 52.28 41.82 IMA of Louisiana Commercial PPO 44.44 percent of total billed charges 28.75 44.44 Reimbursement at 85% of billed charges DRAPE MINI C-ARM 272 RC outpatient 52.28 41.82 Aetna Commercial PPO 28.75 percent of total billed charges 28.75 44.44 55 of billed Charges TELFA ISLAND DRESSING 4 X 14 272 RC inpatient 4.28 2.14 BCBS Louisiana PPO 2.14 percent of total billed charges 2.14 3.64 50% of Eligible Charges TELFA ISLAND DRESSING 4 X 14 272 RC outpatient 4.28 3.42 BCBS Louisiana PPO 3.42 percent of total billed charges 2.35 3.64 80% of billed charge TELFA ISLAND DRESSING 4 X 14 272 RC outpatient 4.28 3.42 Cigna Commercial PPO 2.35 percent of total billed charges 2.35 3.64 55% of Billed Charges TELFA ISLAND DRESSING 4 X 14 272 RC inpatient 4.28 2.14 IMA of Louisiana Commercial PPO 3.64 percent of total billed charges 2.14 3.64 Inpatient Reimbursement at 85% of Billed Charges TELFA ISLAND DRESSING 4 X 14 272 RC outpatient 4.28 3.42 IMA of Louisiana Commercial PPO 3.64 percent of total billed charges 2.35 3.64 Reimbursement at 85% of billed charges TELFA ISLAND DRESSING 4 X 14 272 RC outpatient 4.28 3.42 Aetna Commercial PPO 2.35 percent of total billed charges 2.35 3.64 55 of billed Charges ELECTROCAUTERY 0014AM (4 ) 272 RC inpatient 44.92 22.46 BCBS Louisiana PPO 22.46 percent of total billed charges 22.46 38.18 50% of Eligible Charges ELECTROCAUTERY 0014AM (4 ) 272 RC outpatient 44.92 35.94 BCBS Louisiana PPO 35.94 percent of total billed charges 24.71 38.18 80% of billed charge ELECTROCAUTERY 0014AM (4 ) 272 RC outpatient 44.92 35.94 Cigna Commercial PPO 24.71 percent of total billed charges 24.71 38.18 55% of Billed Charges ELECTROCAUTERY 0014AM (4 ) 272 RC inpatient 44.92 22.46 IMA of Louisiana Commercial PPO 38.18 percent of total billed charges 22.46 38.18 Inpatient Reimbursement at 85% of Billed Charges ELECTROCAUTERY 0014AM (4 ) 272 RC outpatient 44.92 35.94 IMA of Louisiana Commercial PPO 38.18 percent of total billed charges 24.71 38.18 Reimbursement at 85% of billed charges ELECTROCAUTERY 0014AM (4 ) 272 RC outpatient 44.92 35.94 Aetna Commercial PPO 24.71 percent of total billed charges 24.71 38.18 55 of billed Charges GLOVE BIOGEL SZ 7.0 272 RC inpatient 10.48 5.24 BCBS Louisiana PPO 5.24 percent of total billed charges 5.24 8.91 50% of Eligible Charges GLOVE BIOGEL SZ 7.0 272 RC outpatient 10.48 8.38 BCBS Louisiana PPO 8.38 percent of total billed charges 5.76 8.91 80% of billed charge GLOVE BIOGEL SZ 7.0 272 RC outpatient 10.48 8.38 Cigna Commercial PPO 5.76 percent of total billed charges 5.76 8.91 55% of Billed Charges GLOVE BIOGEL SZ 7.0 272 RC inpatient 10.48 5.24 IMA of Louisiana Commercial PPO 8.91 percent of total billed charges 5.24 8.91 Inpatient Reimbursement at 85% of Billed Charges GLOVE BIOGEL SZ 7.0 272 RC outpatient 10.48 8.38 IMA of Louisiana Commercial PPO 8.91 percent of total billed charges 5.76 8.91 Reimbursement at 85% of billed charges GLOVE BIOGEL SZ 7.0 272 RC outpatient 10.48 8.38 Aetna Commercial PPO 5.76 percent of total billed charges 5.76 8.91 55 of billed Charges GLOVE ORTHO 8.0 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges GLOVE ORTHO 8.0 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge GLOVE ORTHO 8.0 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges GLOVE ORTHO 8.0 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges GLOVE ORTHO 8.0 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges GLOVE ORTHO 8.0 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges GLOVE STERILE 6.0 LTX 272 RC inpatient 77.84 38.92 BCBS Louisiana PPO 38.92 percent of total billed charges 38.92 66.16 50% of Eligible Charges GLOVE STERILE 6.0 LTX 272 RC outpatient 77.84 62.27 BCBS Louisiana PPO 62.27 percent of total billed charges 42.81 66.16 80% of billed charge GLOVE STERILE 6.0 LTX 272 RC outpatient 77.84 62.27 Cigna Commercial PPO 42.81 percent of total billed charges 42.81 66.16 55% of Billed Charges GLOVE STERILE 6.0 LTX 272 RC inpatient 77.84 38.92 IMA of Louisiana Commercial PPO 66.16 percent of total billed charges 38.92 66.16 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 6.0 LTX 272 RC outpatient 77.84 62.27 IMA of Louisiana Commercial PPO 66.16 percent of total billed charges 42.81 66.16 Reimbursement at 85% of billed charges GLOVE STERILE 6.0 LTX 272 RC outpatient 77.84 62.27 Aetna Commercial PPO 42.81 percent of total billed charges 42.81 66.16 55 of billed Charges STEINMAN PIN 3.6MM C1713 HCPCS 272 RC inpatient 477.75 238.88 BCBS Louisiana PPO 238.88 percent of total billed charges 238.88 406.09 50% of Eligible Charges STEINMAN PIN 3.6MM C1713 HCPCS 272 RC outpatient 477.75 382.2 BCBS Louisiana PPO 382.2 percent of total billed charges 262.76 406.09 80% of billed charge STEINMAN PIN 3.6MM C1713 HCPCS 272 RC outpatient 477.75 382.2 Cigna Commercial PPO 262.76 percent of total billed charges 262.76 406.09 55% of Billed Charges STEINMAN PIN 3.6MM C1713 HCPCS 272 RC inpatient 477.75 238.88 IMA of Louisiana Commercial PPO 406.09 percent of total billed charges 238.88 406.09 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 3.6MM C1713 HCPCS 272 RC outpatient 477.75 382.2 IMA of Louisiana Commercial PPO 406.09 percent of total billed charges 262.76 406.09 Reimbursement at 85% of billed charges STEINMAN PIN 3.6MM C1713 HCPCS 272 RC outpatient 477.75 382.2 Aetna Commercial PPO 262.76 percent of total billed charges 262.76 406.09 55 of billed Charges IODOFORM NUGAUZE PACKING 1/2 272 RC inpatient 11 5.5 BCBS Louisiana PPO 5.5 percent of total billed charges 5.5 9.35 50% of Eligible Charges IODOFORM NUGAUZE PACKING 1/2 272 RC outpatient 11 8.8 BCBS Louisiana PPO 8.8 percent of total billed charges 6.05 9.35 80% of billed charge IODOFORM NUGAUZE PACKING 1/2 272 RC outpatient 11 8.8 Cigna Commercial PPO 6.05 percent of total billed charges 6.05 9.35 55% of Billed Charges IODOFORM NUGAUZE PACKING 1/2 272 RC inpatient 11 5.5 IMA of Louisiana Commercial PPO 9.35 percent of total billed charges 5.5 9.35 Inpatient Reimbursement at 85% of Billed Charges IODOFORM NUGAUZE PACKING 1/2 272 RC outpatient 11 8.8 IMA of Louisiana Commercial PPO 9.35 percent of total billed charges 6.05 9.35 Reimbursement at 85% of billed charges IODOFORM NUGAUZE PACKING 1/2 272 RC outpatient 11 8.8 Aetna Commercial PPO 6.05 percent of total billed charges 6.05 9.35 55 of billed Charges IV CATH 22G INTROCAN 272 RC inpatient 5.64 2.82 BCBS Louisiana PPO 2.82 percent of total billed charges 2.82 4.79 50% of Eligible Charges IV CATH 22G INTROCAN 272 RC outpatient 5.64 4.51 BCBS Louisiana PPO 4.51 percent of total billed charges 3.1 4.79 80% of billed charge IV CATH 22G INTROCAN 272 RC outpatient 5.64 4.51 Cigna Commercial PPO 3.1 percent of total billed charges 3.1 4.79 55% of Billed Charges IV CATH 22G INTROCAN 272 RC inpatient 5.64 2.82 IMA of Louisiana Commercial PPO 4.79 percent of total billed charges 2.82 4.79 Inpatient Reimbursement at 85% of Billed Charges IV CATH 22G INTROCAN 272 RC outpatient 5.64 4.51 IMA of Louisiana Commercial PPO 4.79 percent of total billed charges 3.1 4.79 Reimbursement at 85% of billed charges IV CATH 22G INTROCAN 272 RC outpatient 5.64 4.51 Aetna Commercial PPO 3.1 percent of total billed charges 3.1 4.79 55 of billed Charges KLING 3 272 RC inpatient 20.44 10.22 BCBS Louisiana PPO 10.22 percent of total billed charges 10.22 17.37 50% of Eligible Charges KLING 3 272 RC outpatient 20.44 16.35 BCBS Louisiana PPO 16.35 percent of total billed charges 11.24 17.37 80% of billed charge KLING 3 272 RC outpatient 20.44 16.35 Cigna Commercial PPO 11.24 percent of total billed charges 11.24 17.37 55% of Billed Charges KLING 3 272 RC inpatient 20.44 10.22 IMA of Louisiana Commercial PPO 17.37 percent of total billed charges 10.22 17.37 Inpatient Reimbursement at 85% of Billed Charges KLING 3 272 RC outpatient 20.44 16.35 IMA of Louisiana Commercial PPO 17.37 percent of total billed charges 11.24 17.37 Reimbursement at 85% of billed charges KLING 3 272 RC outpatient 20.44 16.35 Aetna Commercial PPO 11.24 percent of total billed charges 11.24 17.37 55 of billed Charges ADAPTIC DRESSING 3 X 3 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges ADAPTIC DRESSING 3 X 3 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge ADAPTIC DRESSING 3 X 3 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges ADAPTIC DRESSING 3 X 3 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges ADAPTIC DRESSING 3 X 3 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges ADAPTIC DRESSING 3 X 3 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 393.05 196.53 BCBS Louisiana PPO 196.53 percent of total billed charges 196.53 334.09 50% of Eligible Charges SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 BCBS Louisiana PPO 314.44 percent of total billed charges 145.43 334.09 80% of billed charge SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 Cigna Commercial PPO 227.97 percent of total billed charges 145.43 334.09 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 393.05 196.53 IMA of Louisiana Commercial PPO 334.09 percent of total billed charges 196.53 334.09 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 IMA of Louisiana Commercial PPO 334.09 percent of total billed charges 145.43 334.09 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 393.05 314.44 Aetna Commercial PPO 145.43 percent of total billed charges 145.43 334.09 37% Of Billed Charges 2000 K-WIRE NON-THREADED .035 272 RC inpatient 150 75 BCBS Louisiana PPO 75 percent of total billed charges 75 127.5 50% of Eligible Charges K-WIRE NON-THREADED .035 272 RC outpatient 150 120 BCBS Louisiana PPO 120 percent of total billed charges 82.5 127.5 80% of billed charge K-WIRE NON-THREADED .035 272 RC outpatient 150 120 Cigna Commercial PPO 82.5 percent of total billed charges 82.5 127.5 55% of Billed Charges K-WIRE NON-THREADED .035 272 RC inpatient 150 75 IMA of Louisiana Commercial PPO 127.5 percent of total billed charges 75 127.5 Inpatient Reimbursement at 85% of Billed Charges K-WIRE NON-THREADED .035 272 RC outpatient 150 120 IMA of Louisiana Commercial PPO 127.5 percent of total billed charges 82.5 127.5 Reimbursement at 85% of billed charges K-WIRE NON-THREADED .035 272 RC outpatient 150 120 Aetna Commercial PPO 82.5 percent of total billed charges 82.5 127.5 55 of billed Charges K-WIRE NON-THREADED .062 272 RC inpatient 131.25 65.63 BCBS Louisiana PPO 65.63 percent of total billed charges 65.63 111.56 50% of Eligible Charges K-WIRE NON-THREADED .062 272 RC outpatient 131.25 105 BCBS Louisiana PPO 105 percent of total billed charges 72.19 111.56 80% of billed charge K-WIRE NON-THREADED .062 272 RC outpatient 131.25 105 Cigna Commercial PPO 72.19 percent of total billed charges 72.19 111.56 55% of Billed Charges K-WIRE NON-THREADED .062 272 RC inpatient 131.25 65.63 IMA of Louisiana Commercial PPO 111.56 percent of total billed charges 65.63 111.56 Inpatient Reimbursement at 85% of Billed Charges K-WIRE NON-THREADED .062 272 RC outpatient 131.25 105 IMA of Louisiana Commercial PPO 111.56 percent of total billed charges 72.19 111.56 Reimbursement at 85% of billed charges K-WIRE NON-THREADED .062 272 RC outpatient 131.25 105 Aetna Commercial PPO 72.19 percent of total billed charges 72.19 111.56 55 of billed Charges NEEDLE RC 35 MM 272 RC inpatient 340.52 170.26 BCBS Louisiana PPO 170.26 percent of total billed charges 170.26 289.44 50% of Eligible Charges NEEDLE RC 35 MM 272 RC outpatient 340.52 272.42 BCBS Louisiana PPO 272.42 percent of total billed charges 187.29 289.44 80% of billed charge NEEDLE RC 35 MM 272 RC outpatient 340.52 272.42 Cigna Commercial PPO 187.29 percent of total billed charges 187.29 289.44 55% of Billed Charges NEEDLE RC 35 MM 272 RC inpatient 340.52 170.26 IMA of Louisiana Commercial PPO 289.44 percent of total billed charges 170.26 289.44 Inpatient Reimbursement at 85% of Billed Charges NEEDLE RC 35 MM 272 RC outpatient 340.52 272.42 IMA of Louisiana Commercial PPO 289.44 percent of total billed charges 187.29 289.44 Reimbursement at 85% of billed charges NEEDLE RC 35 MM 272 RC outpatient 340.52 272.42 Aetna Commercial PPO 187.29 percent of total billed charges 187.29 289.44 55 of billed Charges PIN BALL .035 270 RC inpatient 154 77 BCBS Louisiana PPO 77 percent of total billed charges 77 130.9 50% of Eligible Charges PIN BALL .035 270 RC outpatient 154 123.2 BCBS Louisiana PPO 123.2 percent of total billed charges 84.7 130.9 80% of billed charge PIN BALL .035 270 RC outpatient 154 123.2 Cigna Commercial PPO 84.7 percent of total billed charges 84.7 130.9 55% of Billed Charges PIN BALL .035 270 RC inpatient 154 77 IMA of Louisiana Commercial PPO 130.9 percent of total billed charges 77 130.9 Inpatient Reimbursement at 85% of Billed Charges PIN BALL .035 270 RC outpatient 154 123.2 IMA of Louisiana Commercial PPO 130.9 percent of total billed charges 84.7 130.9 Reimbursement at 85% of billed charges PIN BALL .035 270 RC outpatient 154 123.2 Aetna Commercial PPO 84.7 percent of total billed charges 84.7 130.9 55 of billed Charges PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC inpatient 203.25 101.63 BCBS Louisiana PPO 101.63 percent of total billed charges 101.63 172.76 50% of Eligible Charges PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 BCBS Louisiana PPO 162.6 percent of total billed charges 75.2 172.76 80% of billed charge PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 Cigna Commercial PPO 117.89 percent of total billed charges 75.2 172.76 58% of Billed Charges/$500 Threshold PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC inpatient 203.25 101.63 IMA of Louisiana Commercial PPO 172.76 percent of total billed charges 101.63 172.76 Inpatient Reimbursement at 85% of Billed Charges PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 IMA of Louisiana Commercial PPO 172.76 percent of total billed charges 75.2 172.76 Reimbursement at 85% of billed charges PLATE 1/3 TUBULAR W/ 4 HOLE 49MM - SYN C1713 HCPCS 278 RC outpatient 203.25 162.6 Aetna Commercial PPO 75.2 percent of total billed charges 75.2 172.76 37% Of Billed Charges 2000 SPECIMEN CONTAINER - STERILE 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SPECIMEN CONTAINER - STERILE 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SPECIMEN CONTAINER - STERILE 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SPECIMEN CONTAINER - STERILE 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SPECIMEN CONTAINER - STERILE 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SPECIMEN CONTAINER - STERILE 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges OR .5 HR 360 RC inpatient 700 350 BCBS Louisiana PPO 350 percent of total billed charges 350 595 50% of Eligible Charges OR .5 HR 360 RC outpatient 700 560 BCBS Louisiana PPO 560 percent of total billed charges 385 595 80% of billed charge OR .5 HR 360 RC outpatient 700 560 Cigna Commercial PPO 385 percent of total billed charges 385 595 55% of Billed Charges OR .5 HR 360 RC inpatient 700 350 IMA of Louisiana Commercial PPO 595 percent of total billed charges 350 595 Inpatient Reimbursement at 85% of Billed Charges OR .5 HR 360 RC outpatient 700 560 IMA of Louisiana Commercial PPO 595 percent of total billed charges 385 595 Reimbursement at 85% of billed charges OR .5 HR 360 RC outpatient 700 560 Aetna Commercial PPO 385 percent of total billed charges 385 595 55 of billed Charges ABD PAD 5 X 9 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges ABD PAD 5 X 9 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge ABD PAD 5 X 9 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges ABD PAD 5 X 9 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges ABD PAD 5 X 9 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges ABD PAD 5 X 9 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges AIRWAY BERMAN 90MM 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges AIRWAY BERMAN 90MM 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge AIRWAY BERMAN 90MM 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges AIRWAY BERMAN 90MM 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges AIRWAY BERMAN 90MM 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges AIRWAY BERMAN 90MM 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 224 112 BCBS Louisiana PPO 112 percent of total billed charges 112 190.4 50% of Eligible Charges STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 224 179.2 BCBS Louisiana PPO 179.2 percent of total billed charges 82.88 190.4 80% of billed charge STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 224 179.2 Cigna Commercial PPO 129.92 percent of total billed charges 82.88 190.4 58% of Billed Charges/$500 Threshold STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC inpatient 224 112 IMA of Louisiana Commercial PPO 190.4 percent of total billed charges 112 190.4 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 224 179.2 IMA of Louisiana Commercial PPO 190.4 percent of total billed charges 82.88 190.4 Reimbursement at 85% of billed charges STEINMAN PIN 2.0MM - ZIMMER SET C1713 HCPCS 278 RC outpatient 224 179.2 Aetna Commercial PPO 82.88 percent of total billed charges 82.88 190.4 37% Of Billed Charges 2000 ULNA / HEEL PAD 270 RC inpatient 15.44 7.72 BCBS Louisiana PPO 7.72 percent of total billed charges 7.72 13.12 50% of Eligible Charges ULNA / HEEL PAD 270 RC outpatient 15.44 12.35 BCBS Louisiana PPO 12.35 percent of total billed charges 8.49 13.12 80% of billed charge ULNA / HEEL PAD 270 RC outpatient 15.44 12.35 Cigna Commercial PPO 8.49 percent of total billed charges 8.49 13.12 55% of Billed Charges ULNA / HEEL PAD 270 RC inpatient 15.44 7.72 IMA of Louisiana Commercial PPO 13.12 percent of total billed charges 7.72 13.12 Inpatient Reimbursement at 85% of Billed Charges ULNA / HEEL PAD 270 RC outpatient 15.44 12.35 IMA of Louisiana Commercial PPO 13.12 percent of total billed charges 8.49 13.12 Reimbursement at 85% of billed charges ULNA / HEEL PAD 270 RC outpatient 15.44 12.35 Aetna Commercial PPO 8.49 percent of total billed charges 8.49 13.12 55 of billed Charges ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC inpatient 250.6 125.3 BCBS Louisiana PPO 125.3 percent of total billed charges 125.3 213.01 50% of Eligible Charges ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC outpatient 250.6 200.48 BCBS Louisiana PPO 200.48 percent of total billed charges 137.83 213.01 80% of billed charge ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC outpatient 250.6 200.48 Cigna Commercial PPO 137.83 percent of total billed charges 137.83 213.01 55% of Billed Charges ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC inpatient 250.6 125.3 IMA of Louisiana Commercial PPO 213.01 percent of total billed charges 125.3 213.01 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC outpatient 250.6 200.48 IMA of Louisiana Commercial PPO 213.01 percent of total billed charges 137.83 213.01 Reimbursement at 85% of billed charges ARTHROSCOPY 4.0 AGG PLUS SHV 272 RC outpatient 250.6 200.48 Aetna Commercial PPO 137.83 percent of total billed charges 137.83 213.01 55 of billed Charges ARTHROSCOPY CUSTOM PACK 272 RC inpatient 374.37 187.19 BCBS Louisiana PPO 187.19 percent of total billed charges 187.19 318.21 50% of Eligible Charges ARTHROSCOPY CUSTOM PACK 272 RC outpatient 374.37 299.5 BCBS Louisiana PPO 299.5 percent of total billed charges 205.9 318.21 80% of billed charge ARTHROSCOPY CUSTOM PACK 272 RC outpatient 374.37 299.5 Cigna Commercial PPO 205.9 percent of total billed charges 205.9 318.21 55% of Billed Charges ARTHROSCOPY CUSTOM PACK 272 RC inpatient 374.37 187.19 IMA of Louisiana Commercial PPO 318.21 percent of total billed charges 187.19 318.21 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY CUSTOM PACK 272 RC outpatient 374.37 299.5 IMA of Louisiana Commercial PPO 318.21 percent of total billed charges 205.9 318.21 Reimbursement at 85% of billed charges ARTHROSCOPY CUSTOM PACK 272 RC outpatient 374.37 299.5 Aetna Commercial PPO 205.9 percent of total billed charges 205.9 318.21 55 of billed Charges STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC inpatient 280 140 BCBS Louisiana PPO 140 percent of total billed charges 140 238 50% of Eligible Charges STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 BCBS Louisiana PPO 224 percent of total billed charges 154 238 80% of billed charge STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 Cigna Commercial PPO 154 percent of total billed charges 154 238 55% of Billed Charges STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC inpatient 280 140 IMA of Louisiana Commercial PPO 238 percent of total billed charges 140 238 Inpatient Reimbursement at 85% of Billed Charges STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 IMA of Louisiana Commercial PPO 238 percent of total billed charges 154 238 Reimbursement at 85% of billed charges STEINMAN PIN 4.8MM - ZIMMER SET C1713 HCPCS 272 RC outpatient 280 224 Aetna Commercial PPO 154 percent of total billed charges 154 238 55 of billed Charges BIO PREP BONE KIT 272 RC inpatient 777 388.5 BCBS Louisiana PPO 388.5 percent of total billed charges 388.5 660.45 50% of Eligible Charges BIO PREP BONE KIT 272 RC outpatient 777 621.6 BCBS Louisiana PPO 621.6 percent of total billed charges 427.35 660.45 80% of billed charge BIO PREP BONE KIT 272 RC outpatient 777 621.6 Cigna Commercial PPO 427.35 percent of total billed charges 427.35 660.45 55% of Billed Charges BIO PREP BONE KIT 272 RC inpatient 777 388.5 IMA of Louisiana Commercial PPO 660.45 percent of total billed charges 388.5 660.45 Inpatient Reimbursement at 85% of Billed Charges BIO PREP BONE KIT 272 RC outpatient 777 621.6 IMA of Louisiana Commercial PPO 660.45 percent of total billed charges 427.35 660.45 Reimbursement at 85% of billed charges BIO PREP BONE KIT 272 RC outpatient 777 621.6 Aetna Commercial PPO 427.35 percent of total billed charges 427.35 660.45 55 of billed Charges DRAIN CHEST SGL COLL SRY SCTN 272 RC inpatient 199.12 99.56 BCBS Louisiana PPO 99.56 percent of total billed charges 99.56 169.25 50% of Eligible Charges DRAIN CHEST SGL COLL SRY SCTN 272 RC outpatient 199.12 159.3 BCBS Louisiana PPO 159.3 percent of total billed charges 109.52 169.25 80% of billed charge DRAIN CHEST SGL COLL SRY SCTN 272 RC outpatient 199.12 159.3 Cigna Commercial PPO 109.52 percent of total billed charges 109.52 169.25 55% of Billed Charges DRAIN CHEST SGL COLL SRY SCTN 272 RC inpatient 199.12 99.56 IMA of Louisiana Commercial PPO 169.25 percent of total billed charges 99.56 169.25 Inpatient Reimbursement at 85% of Billed Charges DRAIN CHEST SGL COLL SRY SCTN 272 RC outpatient 199.12 159.3 IMA of Louisiana Commercial PPO 169.25 percent of total billed charges 109.52 169.25 Reimbursement at 85% of billed charges DRAIN CHEST SGL COLL SRY SCTN 272 RC outpatient 199.12 159.3 Aetna Commercial PPO 109.52 percent of total billed charges 109.52 169.25 55 of billed Charges BOXER SHORTS MED 3RD FLOOR 270 RC inpatient 87 43.5 BCBS Louisiana PPO 43.5 percent of total billed charges 43.5 73.95 50% of Eligible Charges BOXER SHORTS MED 3RD FLOOR 270 RC outpatient 87 69.6 BCBS Louisiana PPO 69.6 percent of total billed charges 47.85 73.95 80% of billed charge BOXER SHORTS MED 3RD FLOOR 270 RC outpatient 87 69.6 Cigna Commercial PPO 47.85 percent of total billed charges 47.85 73.95 55% of Billed Charges BOXER SHORTS MED 3RD FLOOR 270 RC inpatient 87 43.5 IMA of Louisiana Commercial PPO 73.95 percent of total billed charges 43.5 73.95 Inpatient Reimbursement at 85% of Billed Charges BOXER SHORTS MED 3RD FLOOR 270 RC outpatient 87 69.6 IMA of Louisiana Commercial PPO 73.95 percent of total billed charges 47.85 73.95 Reimbursement at 85% of billed charges BOXER SHORTS MED 3RD FLOOR 270 RC outpatient 87 69.6 Aetna Commercial PPO 47.85 percent of total billed charges 47.85 73.95 55 of billed Charges BUR 2.3MM ROUND 1608-2-9 272 RC inpatient 62.4 31.2 BCBS Louisiana PPO 31.2 percent of total billed charges 31.2 53.04 50% of Eligible Charges BUR 2.3MM ROUND 1608-2-9 272 RC outpatient 62.4 49.92 BCBS Louisiana PPO 49.92 percent of total billed charges 34.32 53.04 80% of billed charge BUR 2.3MM ROUND 1608-2-9 272 RC outpatient 62.4 49.92 Cigna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55% of Billed Charges BUR 2.3MM ROUND 1608-2-9 272 RC inpatient 62.4 31.2 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 31.2 53.04 Inpatient Reimbursement at 85% of Billed Charges BUR 2.3MM ROUND 1608-2-9 272 RC outpatient 62.4 49.92 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 34.32 53.04 Reimbursement at 85% of billed charges BUR 2.3MM ROUND 1608-2-9 272 RC outpatient 62.4 49.92 Aetna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55 of billed Charges CAST PADDING 6 270 RC inpatient 4.11 2.06 BCBS Louisiana PPO 2.06 percent of total billed charges 2.06 3.49 50% of Eligible Charges CAST PADDING 6 270 RC outpatient 4.11 3.29 BCBS Louisiana PPO 3.29 percent of total billed charges 2.26 3.49 80% of billed charge CAST PADDING 6 270 RC outpatient 4.11 3.29 Cigna Commercial PPO 2.26 percent of total billed charges 2.26 3.49 55% of Billed Charges CAST PADDING 6 270 RC inpatient 4.11 2.06 IMA of Louisiana Commercial PPO 3.49 percent of total billed charges 2.06 3.49 Inpatient Reimbursement at 85% of Billed Charges CAST PADDING 6 270 RC outpatient 4.11 3.29 IMA of Louisiana Commercial PPO 3.49 percent of total billed charges 2.26 3.49 Reimbursement at 85% of billed charges CAST PADDING 6 270 RC outpatient 4.11 3.29 Aetna Commercial PPO 2.26 percent of total billed charges 2.26 3.49 55 of billed Charges SUCTION CATHETER 10FR 272 RC inpatient 84 42 BCBS Louisiana PPO 42 percent of total billed charges 42 71.4 50% of Eligible Charges SUCTION CATHETER 10FR 272 RC outpatient 84 67.2 BCBS Louisiana PPO 67.2 percent of total billed charges 46.2 71.4 80% of billed charge SUCTION CATHETER 10FR 272 RC outpatient 84 67.2 Cigna Commercial PPO 46.2 percent of total billed charges 46.2 71.4 55% of Billed Charges SUCTION CATHETER 10FR 272 RC inpatient 84 42 IMA of Louisiana Commercial PPO 71.4 percent of total billed charges 42 71.4 Inpatient Reimbursement at 85% of Billed Charges SUCTION CATHETER 10FR 272 RC outpatient 84 67.2 IMA of Louisiana Commercial PPO 71.4 percent of total billed charges 46.2 71.4 Reimbursement at 85% of billed charges SUCTION CATHETER 10FR 272 RC outpatient 84 67.2 Aetna Commercial PPO 46.2 percent of total billed charges 46.2 71.4 55 of billed Charges FLO-SEAL 10ML 272 RC inpatient 2761.48 1380.74 BCBS Louisiana PPO 1380.74 percent of total billed charges 1380.74 2347.26 50% of Eligible Charges FLO-SEAL 10ML 272 RC outpatient 2761.48 2209.18 BCBS Louisiana PPO 2209.18 percent of total billed charges 1518.81 2347.26 80% of billed charge FLO-SEAL 10ML 272 RC outpatient 2761.48 2209.18 Cigna Commercial PPO 1518.81 percent of total billed charges 1518.81 2347.26 55% of Billed Charges FLO-SEAL 10ML 272 RC inpatient 2761.48 1380.74 IMA of Louisiana Commercial PPO 2347.26 percent of total billed charges 1380.74 2347.26 Inpatient Reimbursement at 85% of Billed Charges FLO-SEAL 10ML 272 RC outpatient 2761.48 2209.18 IMA of Louisiana Commercial PPO 2347.26 percent of total billed charges 1518.81 2347.26 Reimbursement at 85% of billed charges FLO-SEAL 10ML 272 RC outpatient 2761.48 2209.18 Aetna Commercial PPO 1518.81 percent of total billed charges 1518.81 2347.26 55 of billed Charges CLIPPER LIGATIN APPLIER SH SM 272 RC inpatient 243.15 121.58 BCBS Louisiana PPO 121.58 percent of total billed charges 121.58 206.68 50% of Eligible Charges CLIPPER LIGATIN APPLIER SH SM 272 RC outpatient 243.15 194.52 BCBS Louisiana PPO 194.52 percent of total billed charges 133.73 206.68 80% of billed charge CLIPPER LIGATIN APPLIER SH SM 272 RC outpatient 243.15 194.52 Cigna Commercial PPO 133.73 percent of total billed charges 133.73 206.68 55% of Billed Charges CLIPPER LIGATIN APPLIER SH SM 272 RC inpatient 243.15 121.58 IMA of Louisiana Commercial PPO 206.68 percent of total billed charges 121.58 206.68 Inpatient Reimbursement at 85% of Billed Charges CLIPPER LIGATIN APPLIER SH SM 272 RC outpatient 243.15 194.52 IMA of Louisiana Commercial PPO 206.68 percent of total billed charges 133.73 206.68 Reimbursement at 85% of billed charges CLIPPER LIGATIN APPLIER SH SM 272 RC outpatient 243.15 194.52 Aetna Commercial PPO 133.73 percent of total billed charges 133.73 206.68 55 of billed Charges CRUTCH ALUM DRESSED YOUTH 270 RC inpatient 166.39 83.2 BCBS Louisiana PPO 83.2 percent of total billed charges 83.2 141.43 50% of Eligible Charges CRUTCH ALUM DRESSED YOUTH 270 RC outpatient 166.39 133.11 BCBS Louisiana PPO 133.11 percent of total billed charges 91.51 141.43 80% of billed charge CRUTCH ALUM DRESSED YOUTH 270 RC outpatient 166.39 133.11 Cigna Commercial PPO 91.51 percent of total billed charges 91.51 141.43 55% of Billed Charges CRUTCH ALUM DRESSED YOUTH 270 RC inpatient 166.39 83.2 IMA of Louisiana Commercial PPO 141.43 percent of total billed charges 83.2 141.43 Inpatient Reimbursement at 85% of Billed Charges CRUTCH ALUM DRESSED YOUTH 270 RC outpatient 166.39 133.11 IMA of Louisiana Commercial PPO 141.43 percent of total billed charges 91.51 141.43 Reimbursement at 85% of billed charges CRUTCH ALUM DRESSED YOUTH 270 RC outpatient 166.39 133.11 Aetna Commercial PPO 91.51 percent of total billed charges 91.51 141.43 55 of billed Charges DRAPE ANDREWS TABLE KIT 270 RC inpatient 595 297.5 BCBS Louisiana PPO 297.5 percent of total billed charges 297.5 505.75 50% of Eligible Charges DRAPE ANDREWS TABLE KIT 270 RC outpatient 595 476 BCBS Louisiana PPO 476 percent of total billed charges 327.25 505.75 80% of billed charge DRAPE ANDREWS TABLE KIT 270 RC outpatient 595 476 Cigna Commercial PPO 327.25 percent of total billed charges 327.25 505.75 55% of Billed Charges DRAPE ANDREWS TABLE KIT 270 RC inpatient 595 297.5 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 297.5 505.75 Inpatient Reimbursement at 85% of Billed Charges DRAPE ANDREWS TABLE KIT 270 RC outpatient 595 476 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 327.25 505.75 Reimbursement at 85% of billed charges DRAPE ANDREWS TABLE KIT 270 RC outpatient 595 476 Aetna Commercial PPO 327.25 percent of total billed charges 327.25 505.75 55 of billed Charges DRAPE C-ARM MICROTEK 272 RC inpatient 62.91 31.46 BCBS Louisiana PPO 31.46 percent of total billed charges 31.46 53.47 50% of Eligible Charges DRAPE C-ARM MICROTEK 272 RC outpatient 62.91 50.33 BCBS Louisiana PPO 50.33 percent of total billed charges 34.6 53.47 80% of billed charge DRAPE C-ARM MICROTEK 272 RC outpatient 62.91 50.33 Cigna Commercial PPO 34.6 percent of total billed charges 34.6 53.47 55% of Billed Charges DRAPE C-ARM MICROTEK 272 RC inpatient 62.91 31.46 IMA of Louisiana Commercial PPO 53.47 percent of total billed charges 31.46 53.47 Inpatient Reimbursement at 85% of Billed Charges DRAPE C-ARM MICROTEK 272 RC outpatient 62.91 50.33 IMA of Louisiana Commercial PPO 53.47 percent of total billed charges 34.6 53.47 Reimbursement at 85% of billed charges DRAPE C-ARM MICROTEK 272 RC outpatient 62.91 50.33 Aetna Commercial PPO 34.6 percent of total billed charges 34.6 53.47 55 of billed Charges DRAPE SHOULDER BEACHCHAIR 272 RC inpatient 119.28 59.64 BCBS Louisiana PPO 59.64 percent of total billed charges 59.64 101.39 50% of Eligible Charges DRAPE SHOULDER BEACHCHAIR 272 RC outpatient 119.28 95.42 BCBS Louisiana PPO 95.42 percent of total billed charges 65.6 101.39 80% of billed charge DRAPE SHOULDER BEACHCHAIR 272 RC outpatient 119.28 95.42 Cigna Commercial PPO 65.6 percent of total billed charges 65.6 101.39 55% of Billed Charges DRAPE SHOULDER BEACHCHAIR 272 RC inpatient 119.28 59.64 IMA of Louisiana Commercial PPO 101.39 percent of total billed charges 59.64 101.39 Inpatient Reimbursement at 85% of Billed Charges DRAPE SHOULDER BEACHCHAIR 272 RC outpatient 119.28 95.42 IMA of Louisiana Commercial PPO 101.39 percent of total billed charges 65.6 101.39 Reimbursement at 85% of billed charges DRAPE SHOULDER BEACHCHAIR 272 RC outpatient 119.28 95.42 Aetna Commercial PPO 65.6 percent of total billed charges 65.6 101.39 55 of billed Charges DRAPE UTILITY 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges DRAPE UTILITY 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge DRAPE UTILITY 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges DRAPE UTILITY 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges DRAPE UTILITY 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges DRAPE UTILITY 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges ELECTROCAUTERY PENCIL 272 RC inpatient 9.8 4.9 BCBS Louisiana PPO 4.9 percent of total billed charges 4.9 8.33 50% of Eligible Charges ELECTROCAUTERY PENCIL 272 RC outpatient 9.8 7.84 BCBS Louisiana PPO 7.84 percent of total billed charges 5.39 8.33 80% of billed charge ELECTROCAUTERY PENCIL 272 RC outpatient 9.8 7.84 Cigna Commercial PPO 5.39 percent of total billed charges 5.39 8.33 55% of Billed Charges ELECTROCAUTERY PENCIL 272 RC inpatient 9.8 4.9 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 4.9 8.33 Inpatient Reimbursement at 85% of Billed Charges ELECTROCAUTERY PENCIL 272 RC outpatient 9.8 7.84 IMA of Louisiana Commercial PPO 8.33 percent of total billed charges 5.39 8.33 Reimbursement at 85% of billed charges ELECTROCAUTERY PENCIL 272 RC outpatient 9.8 7.84 Aetna Commercial PPO 5.39 percent of total billed charges 5.39 8.33 55 of billed Charges ELECTRODE COATED NEEDLE 2.84 272 RC inpatient 14.12 7.06 BCBS Louisiana PPO 7.06 percent of total billed charges 7.06 12 50% of Eligible Charges ELECTRODE COATED NEEDLE 2.84 272 RC outpatient 14.12 11.3 BCBS Louisiana PPO 11.3 percent of total billed charges 7.77 12 80% of billed charge ELECTRODE COATED NEEDLE 2.84 272 RC outpatient 14.12 11.3 Cigna Commercial PPO 7.77 percent of total billed charges 7.77 12 55% of Billed Charges ELECTRODE COATED NEEDLE 2.84 272 RC inpatient 14.12 7.06 IMA of Louisiana Commercial PPO 12 percent of total billed charges 7.06 12 Inpatient Reimbursement at 85% of Billed Charges ELECTRODE COATED NEEDLE 2.84 272 RC outpatient 14.12 11.3 IMA of Louisiana Commercial PPO 12 percent of total billed charges 7.77 12 Reimbursement at 85% of billed charges ELECTRODE COATED NEEDLE 2.84 272 RC outpatient 14.12 11.3 Aetna Commercial PPO 7.77 percent of total billed charges 7.77 12 55 of billed Charges FINGER FOAM SPLINT 1/2 270 RC inpatient 9.44 4.72 BCBS Louisiana PPO 4.72 percent of total billed charges 4.72 8.02 50% of Eligible Charges FINGER FOAM SPLINT 1/2 270 RC outpatient 9.44 7.55 BCBS Louisiana PPO 7.55 percent of total billed charges 5.19 8.02 80% of billed charge FINGER FOAM SPLINT 1/2 270 RC outpatient 9.44 7.55 Cigna Commercial PPO 5.19 percent of total billed charges 5.19 8.02 55% of Billed Charges FINGER FOAM SPLINT 1/2 270 RC inpatient 9.44 4.72 IMA of Louisiana Commercial PPO 8.02 percent of total billed charges 4.72 8.02 Inpatient Reimbursement at 85% of Billed Charges FINGER FOAM SPLINT 1/2 270 RC outpatient 9.44 7.55 IMA of Louisiana Commercial PPO 8.02 percent of total billed charges 5.19 8.02 Reimbursement at 85% of billed charges FINGER FOAM SPLINT 1/2 270 RC outpatient 9.44 7.55 Aetna Commercial PPO 5.19 percent of total billed charges 5.19 8.02 55 of billed Charges GLOVE STERILE 6.5 LTX 272 RC inpatient 4.38 2.19 BCBS Louisiana PPO 2.19 percent of total billed charges 2.19 3.72 50% of Eligible Charges GLOVE STERILE 6.5 LTX 272 RC outpatient 4.38 3.5 BCBS Louisiana PPO 3.5 percent of total billed charges 2.41 3.72 80% of billed charge GLOVE STERILE 6.5 LTX 272 RC outpatient 4.38 3.5 Cigna Commercial PPO 2.41 percent of total billed charges 2.41 3.72 55% of Billed Charges GLOVE STERILE 6.5 LTX 272 RC inpatient 4.38 2.19 IMA of Louisiana Commercial PPO 3.72 percent of total billed charges 2.19 3.72 Inpatient Reimbursement at 85% of Billed Charges GLOVE STERILE 6.5 LTX 272 RC outpatient 4.38 3.5 IMA of Louisiana Commercial PPO 3.72 percent of total billed charges 2.41 3.72 Reimbursement at 85% of billed charges GLOVE STERILE 6.5 LTX 272 RC outpatient 4.38 3.5 Aetna Commercial PPO 2.41 percent of total billed charges 2.41 3.72 55 of billed Charges GROUNDING PADS 270 RC inpatient 351.75 175.88 BCBS Louisiana PPO 175.88 percent of total billed charges 175.88 298.99 50% of Eligible Charges GROUNDING PADS 270 RC outpatient 351.75 281.4 BCBS Louisiana PPO 281.4 percent of total billed charges 193.46 298.99 80% of billed charge GROUNDING PADS 270 RC outpatient 351.75 281.4 Cigna Commercial PPO 193.46 percent of total billed charges 193.46 298.99 55% of Billed Charges GROUNDING PADS 270 RC inpatient 351.75 175.88 IMA of Louisiana Commercial PPO 298.99 percent of total billed charges 175.88 298.99 Inpatient Reimbursement at 85% of Billed Charges GROUNDING PADS 270 RC outpatient 351.75 281.4 IMA of Louisiana Commercial PPO 298.99 percent of total billed charges 193.46 298.99 Reimbursement at 85% of billed charges GROUNDING PADS 270 RC outpatient 351.75 281.4 Aetna Commercial PPO 193.46 percent of total billed charges 193.46 298.99 55 of billed Charges INTERPULSE SURGILAV 272 RC inpatient 409.15 204.58 BCBS Louisiana PPO 204.58 percent of total billed charges 204.58 347.78 50% of Eligible Charges INTERPULSE SURGILAV 272 RC outpatient 409.15 327.32 BCBS Louisiana PPO 327.32 percent of total billed charges 225.03 347.78 80% of billed charge INTERPULSE SURGILAV 272 RC outpatient 409.15 327.32 Cigna Commercial PPO 225.03 percent of total billed charges 225.03 347.78 55% of Billed Charges INTERPULSE SURGILAV 272 RC inpatient 409.15 204.58 IMA of Louisiana Commercial PPO 347.78 percent of total billed charges 204.58 347.78 Inpatient Reimbursement at 85% of Billed Charges INTERPULSE SURGILAV 272 RC outpatient 409.15 327.32 IMA of Louisiana Commercial PPO 347.78 percent of total billed charges 225.03 347.78 Reimbursement at 85% of billed charges INTERPULSE SURGILAV 272 RC outpatient 409.15 327.32 Aetna Commercial PPO 225.03 percent of total billed charges 225.03 347.78 55 of billed Charges IV CATH 20G INTROCAN 272 RC inpatient 9.65 4.83 BCBS Louisiana PPO 4.83 percent of total billed charges 4.83 8.2 50% of Eligible Charges IV CATH 20G INTROCAN 272 RC outpatient 9.65 7.72 BCBS Louisiana PPO 7.72 percent of total billed charges 5.31 8.2 80% of billed charge IV CATH 20G INTROCAN 272 RC outpatient 9.65 7.72 Cigna Commercial PPO 5.31 percent of total billed charges 5.31 8.2 55% of Billed Charges IV CATH 20G INTROCAN 272 RC inpatient 9.65 4.83 IMA of Louisiana Commercial PPO 8.2 percent of total billed charges 4.83 8.2 Inpatient Reimbursement at 85% of Billed Charges IV CATH 20G INTROCAN 272 RC outpatient 9.65 7.72 IMA of Louisiana Commercial PPO 8.2 percent of total billed charges 5.31 8.2 Reimbursement at 85% of billed charges IV CATH 20G INTROCAN 272 RC outpatient 9.65 7.72 Aetna Commercial PPO 5.31 percent of total billed charges 5.31 8.2 55 of billed Charges BOWL STERILE 272 RC inpatient 246.37 123.19 BCBS Louisiana PPO 123.19 percent of total billed charges 123.19 209.41 50% of Eligible Charges BOWL STERILE 272 RC outpatient 246.37 197.1 BCBS Louisiana PPO 197.1 percent of total billed charges 135.5 209.41 80% of billed charge BOWL STERILE 272 RC outpatient 246.37 197.1 Cigna Commercial PPO 135.5 percent of total billed charges 135.5 209.41 55% of Billed Charges BOWL STERILE 272 RC inpatient 246.37 123.19 IMA of Louisiana Commercial PPO 209.41 percent of total billed charges 123.19 209.41 Inpatient Reimbursement at 85% of Billed Charges BOWL STERILE 272 RC outpatient 246.37 197.1 IMA of Louisiana Commercial PPO 209.41 percent of total billed charges 135.5 209.41 Reimbursement at 85% of billed charges BOWL STERILE 272 RC outpatient 246.37 197.1 Aetna Commercial PPO 135.5 percent of total billed charges 135.5 209.41 55 of billed Charges MAYO STAND COVER (STERILE) 272 RC inpatient 17.23 8.62 BCBS Louisiana PPO 8.62 percent of total billed charges 8.62 14.65 50% of Eligible Charges MAYO STAND COVER (STERILE) 272 RC outpatient 17.23 13.78 BCBS Louisiana PPO 13.78 percent of total billed charges 9.48 14.65 80% of billed charge MAYO STAND COVER (STERILE) 272 RC outpatient 17.23 13.78 Cigna Commercial PPO 9.48 percent of total billed charges 9.48 14.65 55% of Billed Charges MAYO STAND COVER (STERILE) 272 RC inpatient 17.23 8.62 IMA of Louisiana Commercial PPO 14.65 percent of total billed charges 8.62 14.65 Inpatient Reimbursement at 85% of Billed Charges MAYO STAND COVER (STERILE) 272 RC outpatient 17.23 13.78 IMA of Louisiana Commercial PPO 14.65 percent of total billed charges 9.48 14.65 Reimbursement at 85% of billed charges MAYO STAND COVER (STERILE) 272 RC outpatient 17.23 13.78 Aetna Commercial PPO 9.48 percent of total billed charges 9.48 14.65 55 of billed Charges PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC inpatient 572.88 286.44 BCBS Louisiana PPO 286.44 percent of total billed charges 286.44 486.95 50% of Eligible Charges PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC outpatient 572.88 458.3 BCBS Louisiana PPO 458.3 percent of total billed charges 315.08 486.95 80% of billed charge PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC outpatient 572.88 458.3 Cigna Commercial PPO 315.08 percent of total billed charges 315.08 486.95 55% of Billed Charges PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC inpatient 572.88 286.44 IMA of Louisiana Commercial PPO 486.95 percent of total billed charges 286.44 486.95 Inpatient Reimbursement at 85% of Billed Charges PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC outpatient 572.88 458.3 IMA of Louisiana Commercial PPO 486.95 percent of total billed charges 315.08 486.95 Reimbursement at 85% of billed charges PRESSURE PAD-MAKO- FOR TOTAL KNEE 272 RC outpatient 572.88 458.3 Aetna Commercial PPO 315.08 percent of total billed charges 315.08 486.95 55 of billed Charges NEEDLE SPINAL 18G X 3 1/2 272 RC inpatient 10.16 5.08 BCBS Louisiana PPO 5.08 percent of total billed charges 5.08 8.64 50% of Eligible Charges NEEDLE SPINAL 18G X 3 1/2 272 RC outpatient 10.16 8.13 BCBS Louisiana PPO 8.13 percent of total billed charges 5.59 8.64 80% of billed charge NEEDLE SPINAL 18G X 3 1/2 272 RC outpatient 10.16 8.13 Cigna Commercial PPO 5.59 percent of total billed charges 5.59 8.64 55% of Billed Charges NEEDLE SPINAL 18G X 3 1/2 272 RC inpatient 10.16 5.08 IMA of Louisiana Commercial PPO 8.64 percent of total billed charges 5.08 8.64 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 18G X 3 1/2 272 RC outpatient 10.16 8.13 IMA of Louisiana Commercial PPO 8.64 percent of total billed charges 5.59 8.64 Reimbursement at 85% of billed charges NEEDLE SPINAL 18G X 3 1/2 272 RC outpatient 10.16 8.13 Aetna Commercial PPO 5.59 percent of total billed charges 5.59 8.64 55 of billed Charges NEEDLE SPINAL 20G X 3 1/2 272 RC inpatient 10.2 5.1 BCBS Louisiana PPO 5.1 percent of total billed charges 5.1 8.67 50% of Eligible Charges NEEDLE SPINAL 20G X 3 1/2 272 RC outpatient 10.2 8.16 BCBS Louisiana PPO 8.16 percent of total billed charges 5.61 8.67 80% of billed charge NEEDLE SPINAL 20G X 3 1/2 272 RC outpatient 10.2 8.16 Cigna Commercial PPO 5.61 percent of total billed charges 5.61 8.67 55% of Billed Charges NEEDLE SPINAL 20G X 3 1/2 272 RC inpatient 10.2 5.1 IMA of Louisiana Commercial PPO 8.67 percent of total billed charges 5.1 8.67 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 20G X 3 1/2 272 RC outpatient 10.2 8.16 IMA of Louisiana Commercial PPO 8.67 percent of total billed charges 5.61 8.67 Reimbursement at 85% of billed charges NEEDLE SPINAL 20G X 3 1/2 272 RC outpatient 10.2 8.16 Aetna Commercial PPO 5.61 percent of total billed charges 5.61 8.67 55 of billed Charges SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC inpatient 486.75 243.38 BCBS Louisiana PPO 243.38 percent of total billed charges 243.38 413.74 50% of Eligible Charges SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC outpatient 486.75 389.4 BCBS Louisiana PPO 389.4 percent of total billed charges 267.71 413.74 80% of billed charge SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC outpatient 486.75 389.4 Cigna Commercial PPO 267.71 percent of total billed charges 267.71 413.74 55% of Billed Charges SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC inpatient 486.75 243.38 IMA of Louisiana Commercial PPO 413.74 percent of total billed charges 243.38 413.74 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC outpatient 486.75 389.4 IMA of Louisiana Commercial PPO 413.74 percent of total billed charges 267.71 413.74 Reimbursement at 85% of billed charges SUTURE STRATAFIX #2 PDO SXPD2B400 272 RC outpatient 486.75 389.4 Aetna Commercial PPO 267.71 percent of total billed charges 267.71 413.74 55 of billed Charges PLASTER SPLINT 5 X 30 FAST 270 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges PLASTER SPLINT 5 X 30 FAST 270 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge PLASTER SPLINT 5 X 30 FAST 270 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges PLASTER SPLINT 5 X 30 FAST 270 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges PLASTER SPLINT 5 X 30 FAST 270 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges PLASTER SPLINT 5 X 30 FAST 270 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges OMNI-JUG SUCTION CANISTER 15000CC 270 RC inpatient 333.2 166.6 BCBS Louisiana PPO 166.6 percent of total billed charges 166.6 283.22 50% of Eligible Charges OMNI-JUG SUCTION CANISTER 15000CC 270 RC outpatient 333.2 266.56 BCBS Louisiana PPO 266.56 percent of total billed charges 183.26 283.22 80% of billed charge OMNI-JUG SUCTION CANISTER 15000CC 270 RC outpatient 333.2 266.56 Cigna Commercial PPO 183.26 percent of total billed charges 183.26 283.22 55% of Billed Charges OMNI-JUG SUCTION CANISTER 15000CC 270 RC inpatient 333.2 166.6 IMA of Louisiana Commercial PPO 283.22 percent of total billed charges 166.6 283.22 Inpatient Reimbursement at 85% of Billed Charges OMNI-JUG SUCTION CANISTER 15000CC 270 RC outpatient 333.2 266.56 IMA of Louisiana Commercial PPO 283.22 percent of total billed charges 183.26 283.22 Reimbursement at 85% of billed charges OMNI-JUG SUCTION CANISTER 15000CC 270 RC outpatient 333.2 266.56 Aetna Commercial PPO 183.26 percent of total billed charges 183.26 283.22 55 of billed Charges ARTHROSCOPY PUMP TUBING - 272 RC inpatient 922.63 461.32 BCBS Louisiana PPO 461.32 percent of total billed charges 461.32 784.24 50% of Eligible Charges ARTHROSCOPY PUMP TUBING - 272 RC outpatient 922.63 738.1 BCBS Louisiana PPO 738.1 percent of total billed charges 507.45 784.24 80% of billed charge ARTHROSCOPY PUMP TUBING - 272 RC outpatient 922.63 738.1 Cigna Commercial PPO 507.45 percent of total billed charges 507.45 784.24 55% of Billed Charges ARTHROSCOPY PUMP TUBING - 272 RC inpatient 922.63 461.32 IMA of Louisiana Commercial PPO 784.24 percent of total billed charges 461.32 784.24 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY PUMP TUBING - 272 RC outpatient 922.63 738.1 IMA of Louisiana Commercial PPO 784.24 percent of total billed charges 507.45 784.24 Reimbursement at 85% of billed charges ARTHROSCOPY PUMP TUBING - 272 RC outpatient 922.63 738.1 Aetna Commercial PPO 507.45 percent of total billed charges 507.45 784.24 55 of billed Charges SUTURE LASSO CURVE 45 RIGHT SD 272 RC inpatient 441 220.5 BCBS Louisiana PPO 220.5 percent of total billed charges 220.5 374.85 50% of Eligible Charges SUTURE LASSO CURVE 45 RIGHT SD 272 RC outpatient 441 352.8 BCBS Louisiana PPO 352.8 percent of total billed charges 242.55 374.85 80% of billed charge SUTURE LASSO CURVE 45 RIGHT SD 272 RC outpatient 441 352.8 Cigna Commercial PPO 242.55 percent of total billed charges 242.55 374.85 55% of Billed Charges SUTURE LASSO CURVE 45 RIGHT SD 272 RC inpatient 441 220.5 IMA of Louisiana Commercial PPO 374.85 percent of total billed charges 220.5 374.85 Inpatient Reimbursement at 85% of Billed Charges SUTURE LASSO CURVE 45 RIGHT SD 272 RC outpatient 441 352.8 IMA of Louisiana Commercial PPO 374.85 percent of total billed charges 242.55 374.85 Reimbursement at 85% of billed charges SUTURE LASSO CURVE 45 RIGHT SD 272 RC outpatient 441 352.8 Aetna Commercial PPO 242.55 percent of total billed charges 242.55 374.85 55 of billed Charges SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 16MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 28MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC inpatient 906.25 453.13 BCBS Louisiana PPO 453.13 percent of total billed charges 453.13 770.31 50% of Eligible Charges ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC outpatient 906.25 725 BCBS Louisiana PPO 725 percent of total billed charges 498.44 770.31 80% of billed charge ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC outpatient 906.25 725 Cigna Commercial PPO 498.44 percent of total billed charges 498.44 770.31 55% of Billed Charges ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC inpatient 906.25 453.13 IMA of Louisiana Commercial PPO 770.31 percent of total billed charges 453.13 770.31 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC outpatient 906.25 725 IMA of Louisiana Commercial PPO 770.31 percent of total billed charges 498.44 770.31 Reimbursement at 85% of billed charges ARTHROSCOPY SCORPION NEEDLE AR-13990N 272 RC outpatient 906.25 725 Aetna Commercial PPO 498.44 percent of total billed charges 498.44 770.31 55 of billed Charges SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC inpatient 52.11 26.06 BCBS Louisiana PPO 26.06 percent of total billed charges 26.06 44.29 50% of Eligible Charges SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC outpatient 52.11 41.69 BCBS Louisiana PPO 41.69 percent of total billed charges 28.66 44.29 80% of billed charge SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC outpatient 52.11 41.69 Cigna Commercial PPO 28.66 percent of total billed charges 28.66 44.29 55% of Billed Charges SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC inpatient 52.11 26.06 IMA of Louisiana Commercial PPO 44.29 percent of total billed charges 26.06 44.29 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC outpatient 52.11 41.69 IMA of Louisiana Commercial PPO 44.29 percent of total billed charges 28.66 44.29 Reimbursement at 85% of billed charges SODIUM CHLOR .9% 3000ML IRRIGATION - BAG 272 RC outpatient 52.11 41.69 Aetna Commercial PPO 28.66 percent of total billed charges 28.66 44.29 55 of billed Charges SPONGE RAYTEX 272 RC inpatient 6.24 3.12 BCBS Louisiana PPO 3.12 percent of total billed charges 3.12 5.3 50% of Eligible Charges SPONGE RAYTEX 272 RC outpatient 6.24 4.99 BCBS Louisiana PPO 4.99 percent of total billed charges 3.43 5.3 80% of billed charge SPONGE RAYTEX 272 RC outpatient 6.24 4.99 Cigna Commercial PPO 3.43 percent of total billed charges 3.43 5.3 55% of Billed Charges SPONGE RAYTEX 272 RC inpatient 6.24 3.12 IMA of Louisiana Commercial PPO 5.3 percent of total billed charges 3.12 5.3 Inpatient Reimbursement at 85% of Billed Charges SPONGE RAYTEX 272 RC outpatient 6.24 4.99 IMA of Louisiana Commercial PPO 5.3 percent of total billed charges 3.43 5.3 Reimbursement at 85% of billed charges SPONGE RAYTEX 272 RC outpatient 6.24 4.99 Aetna Commercial PPO 3.43 percent of total billed charges 3.43 5.3 55 of billed Charges PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC inpatient 1512.68 756.34 BCBS Louisiana PPO 756.34 percent of total billed charges 756.34 1285.78 50% of Eligible Charges PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC outpatient 1512.68 1210.14 BCBS Louisiana PPO 1210.14 percent of total billed charges 559.69 1285.78 80% of billed charge PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC outpatient 1512.68 1210.14 Cigna Commercial PPO 877.35 percent of total billed charges 559.69 1285.78 58% of Billed Charges/$500 Threshold PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC inpatient 1512.68 756.34 IMA of Louisiana Commercial PPO 1285.78 percent of total billed charges 756.34 1285.78 Inpatient Reimbursement at 85% of Billed Charges PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC outpatient 1512.68 1210.14 IMA of Louisiana Commercial PPO 1285.78 percent of total billed charges 559.69 1285.78 Reimbursement at 85% of billed charges PLATE 3.5MM LCP PROX HUMERUS 3HL C1713 HCPCS 278 RC outpatient 1512.68 1210.14 Aetna Commercial PPO 559.69 percent of total billed charges 559.69 1285.78 37% Of Billed Charges 2000 ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC inpatient 525 262.5 BCBS Louisiana PPO 262.5 percent of total billed charges 262.5 446.25 50% of Eligible Charges ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC outpatient 525 420 BCBS Louisiana PPO 420 percent of total billed charges 288.75 446.25 80% of billed charge ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC outpatient 525 420 Cigna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55% of Billed Charges ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC inpatient 525 262.5 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 262.5 446.25 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC outpatient 525 420 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 288.75 446.25 Reimbursement at 85% of billed charges ARTHROSCOPY 4.5MM INCISOR - S&N ENDO 272 RC outpatient 525 420 Aetna Commercial PPO 288.75 percent of total billed charges 288.75 446.25 55 of billed Charges STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC inpatient 24.92 12.46 BCBS Louisiana PPO 12.46 percent of total billed charges 12.46 21.18 50% of Eligible Charges STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC outpatient 24.92 19.94 BCBS Louisiana PPO 19.94 percent of total billed charges 13.71 21.18 80% of billed charge STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC outpatient 24.92 19.94 Cigna Commercial PPO 13.71 percent of total billed charges 13.71 21.18 55% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC inpatient 24.92 12.46 IMA of Louisiana Commercial PPO 21.18 percent of total billed charges 12.46 21.18 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC outpatient 24.92 19.94 IMA of Louisiana Commercial PPO 21.18 percent of total billed charges 13.71 21.18 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM REG THIGH MED 270 RC outpatient 24.92 19.94 Aetna Commercial PPO 13.71 percent of total billed charges 13.71 21.18 55 of billed Charges SUCTION LINER 3000ML 270 RC inpatient 399.28 199.64 BCBS Louisiana PPO 199.64 percent of total billed charges 199.64 339.39 50% of Eligible Charges SUCTION LINER 3000ML 270 RC outpatient 399.28 319.42 BCBS Louisiana PPO 319.42 percent of total billed charges 219.6 339.39 80% of billed charge SUCTION LINER 3000ML 270 RC outpatient 399.28 319.42 Cigna Commercial PPO 219.6 percent of total billed charges 219.6 339.39 55% of Billed Charges SUCTION LINER 3000ML 270 RC inpatient 399.28 199.64 IMA of Louisiana Commercial PPO 339.39 percent of total billed charges 199.64 339.39 Inpatient Reimbursement at 85% of Billed Charges SUCTION LINER 3000ML 270 RC outpatient 399.28 319.42 IMA of Louisiana Commercial PPO 339.39 percent of total billed charges 219.6 339.39 Reimbursement at 85% of billed charges SUCTION LINER 3000ML 270 RC outpatient 399.28 319.42 Aetna Commercial PPO 219.6 percent of total billed charges 219.6 339.39 55 of billed Charges SUTURE 0 VICRYL CT-2 J270H 272 RC inpatient 6.64 3.32 BCBS Louisiana PPO 3.32 percent of total billed charges 3.32 5.64 50% of Eligible Charges SUTURE 0 VICRYL CT-2 J270H 272 RC outpatient 6.64 5.31 BCBS Louisiana PPO 5.31 percent of total billed charges 3.65 5.64 80% of billed charge SUTURE 0 VICRYL CT-2 J270H 272 RC outpatient 6.64 5.31 Cigna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55% of Billed Charges SUTURE 0 VICRYL CT-2 J270H 272 RC inpatient 6.64 3.32 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.32 5.64 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CT-2 J270H 272 RC outpatient 6.64 5.31 IMA of Louisiana Commercial PPO 5.64 percent of total billed charges 3.65 5.64 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CT-2 J270H 272 RC outpatient 6.64 5.31 Aetna Commercial PPO 3.65 percent of total billed charges 3.65 5.64 55 of billed Charges SUTURE 3-0 ETHILON PS-2 1669H 272 RC inpatient 16.72 8.36 BCBS Louisiana PPO 8.36 percent of total billed charges 8.36 14.21 50% of Eligible Charges SUTURE 3-0 ETHILON PS-2 1669H 272 RC outpatient 16.72 13.38 BCBS Louisiana PPO 13.38 percent of total billed charges 9.2 14.21 80% of billed charge SUTURE 3-0 ETHILON PS-2 1669H 272 RC outpatient 16.72 13.38 Cigna Commercial PPO 9.2 percent of total billed charges 9.2 14.21 55% of Billed Charges SUTURE 3-0 ETHILON PS-2 1669H 272 RC inpatient 16.72 8.36 IMA of Louisiana Commercial PPO 14.21 percent of total billed charges 8.36 14.21 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 ETHILON PS-2 1669H 272 RC outpatient 16.72 13.38 IMA of Louisiana Commercial PPO 14.21 percent of total billed charges 9.2 14.21 Reimbursement at 85% of billed charges SUTURE 3-0 ETHILON PS-2 1669H 272 RC outpatient 16.72 13.38 Aetna Commercial PPO 9.2 percent of total billed charges 9.2 14.21 55 of billed Charges STOCKING KNEE - SMALL 270 RC inpatient 600 300 BCBS Louisiana PPO 300 percent of total billed charges 300 510 50% of Eligible Charges STOCKING KNEE - SMALL 270 RC outpatient 600 480 BCBS Louisiana PPO 480 percent of total billed charges 330 510 80% of billed charge STOCKING KNEE - SMALL 270 RC outpatient 600 480 Cigna Commercial PPO 330 percent of total billed charges 330 510 55% of Billed Charges STOCKING KNEE - SMALL 270 RC inpatient 600 300 IMA of Louisiana Commercial PPO 510 percent of total billed charges 300 510 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - SMALL 270 RC outpatient 600 480 IMA of Louisiana Commercial PPO 510 percent of total billed charges 330 510 Reimbursement at 85% of billed charges STOCKING KNEE - SMALL 270 RC outpatient 600 480 Aetna Commercial PPO 330 percent of total billed charges 330 510 55 of billed Charges ELECTRODE TEFLON 6.5 PLAIN 272 RC inpatient 249.97 124.99 BCBS Louisiana PPO 124.99 percent of total billed charges 124.99 212.47 50% of Eligible Charges ELECTRODE TEFLON 6.5 PLAIN 272 RC outpatient 249.97 199.98 BCBS Louisiana PPO 199.98 percent of total billed charges 137.48 212.47 80% of billed charge ELECTRODE TEFLON 6.5 PLAIN 272 RC outpatient 249.97 199.98 Cigna Commercial PPO 137.48 percent of total billed charges 137.48 212.47 55% of Billed Charges ELECTRODE TEFLON 6.5 PLAIN 272 RC inpatient 249.97 124.99 IMA of Louisiana Commercial PPO 212.47 percent of total billed charges 124.99 212.47 Inpatient Reimbursement at 85% of Billed Charges ELECTRODE TEFLON 6.5 PLAIN 272 RC outpatient 249.97 199.98 IMA of Louisiana Commercial PPO 212.47 percent of total billed charges 137.48 212.47 Reimbursement at 85% of billed charges ELECTRODE TEFLON 6.5 PLAIN 272 RC outpatient 249.97 199.98 Aetna Commercial PPO 137.48 percent of total billed charges 137.48 212.47 55 of billed Charges SUTURE 4-0 VICRYL P-3 J494G 272 RC inpatient 399.98 199.99 BCBS Louisiana PPO 199.99 percent of total billed charges 199.99 339.98 50% of Eligible Charges SUTURE 4-0 VICRYL P-3 J494G 272 RC outpatient 399.98 319.98 BCBS Louisiana PPO 319.98 percent of total billed charges 219.99 339.98 80% of billed charge SUTURE 4-0 VICRYL P-3 J494G 272 RC outpatient 399.98 319.98 Cigna Commercial PPO 219.99 percent of total billed charges 219.99 339.98 55% of Billed Charges SUTURE 4-0 VICRYL P-3 J494G 272 RC inpatient 399.98 199.99 IMA of Louisiana Commercial PPO 339.98 percent of total billed charges 199.99 339.98 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 VICRYL P-3 J494G 272 RC outpatient 399.98 319.98 IMA of Louisiana Commercial PPO 339.98 percent of total billed charges 219.99 339.98 Reimbursement at 85% of billed charges SUTURE 4-0 VICRYL P-3 J494G 272 RC outpatient 399.98 319.98 Aetna Commercial PPO 219.99 percent of total billed charges 219.99 339.98 55 of billed Charges SUTURE 4-0 VICRYL SH J415H 272 RC inpatient 6.56 3.28 BCBS Louisiana PPO 3.28 percent of total billed charges 3.28 5.58 50% of Eligible Charges SUTURE 4-0 VICRYL SH J415H 272 RC outpatient 6.56 5.25 BCBS Louisiana PPO 5.25 percent of total billed charges 3.61 5.58 80% of billed charge SUTURE 4-0 VICRYL SH J415H 272 RC outpatient 6.56 5.25 Cigna Commercial PPO 3.61 percent of total billed charges 3.61 5.58 55% of Billed Charges SUTURE 4-0 VICRYL SH J415H 272 RC inpatient 6.56 3.28 IMA of Louisiana Commercial PPO 5.58 percent of total billed charges 3.28 5.58 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 VICRYL SH J415H 272 RC outpatient 6.56 5.25 IMA of Louisiana Commercial PPO 5.58 percent of total billed charges 3.61 5.58 Reimbursement at 85% of billed charges SUTURE 4-0 VICRYL SH J415H 272 RC outpatient 6.56 5.25 Aetna Commercial PPO 3.61 percent of total billed charges 3.61 5.58 55 of billed Charges STOCKING KNEE - XLG LONG 270 RC inpatient 124.74 62.37 BCBS Louisiana PPO 62.37 percent of total billed charges 62.37 106.03 50% of Eligible Charges STOCKING KNEE - XLG LONG 270 RC outpatient 124.74 99.79 BCBS Louisiana PPO 99.79 percent of total billed charges 68.61 106.03 80% of billed charge STOCKING KNEE - XLG LONG 270 RC outpatient 124.74 99.79 Cigna Commercial PPO 68.61 percent of total billed charges 68.61 106.03 55% of Billed Charges STOCKING KNEE - XLG LONG 270 RC inpatient 124.74 62.37 IMA of Louisiana Commercial PPO 106.03 percent of total billed charges 62.37 106.03 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - XLG LONG 270 RC outpatient 124.74 99.79 IMA of Louisiana Commercial PPO 106.03 percent of total billed charges 68.61 106.03 Reimbursement at 85% of billed charges STOCKING KNEE - XLG LONG 270 RC outpatient 124.74 99.79 Aetna Commercial PPO 68.61 percent of total billed charges 68.61 106.03 55 of billed Charges NEEDLE COUNTER FOAM MAGNET 272 RC inpatient 59.52 29.76 BCBS Louisiana PPO 29.76 percent of total billed charges 29.76 50.59 50% of Eligible Charges NEEDLE COUNTER FOAM MAGNET 272 RC outpatient 59.52 47.62 BCBS Louisiana PPO 47.62 percent of total billed charges 32.74 50.59 80% of billed charge NEEDLE COUNTER FOAM MAGNET 272 RC outpatient 59.52 47.62 Cigna Commercial PPO 32.74 percent of total billed charges 32.74 50.59 55% of Billed Charges NEEDLE COUNTER FOAM MAGNET 272 RC inpatient 59.52 29.76 IMA of Louisiana Commercial PPO 50.59 percent of total billed charges 29.76 50.59 Inpatient Reimbursement at 85% of Billed Charges NEEDLE COUNTER FOAM MAGNET 272 RC outpatient 59.52 47.62 IMA of Louisiana Commercial PPO 50.59 percent of total billed charges 32.74 50.59 Reimbursement at 85% of billed charges NEEDLE COUNTER FOAM MAGNET 272 RC outpatient 59.52 47.62 Aetna Commercial PPO 32.74 percent of total billed charges 32.74 50.59 55 of billed Charges SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC inpatient 560 280 BCBS Louisiana PPO 280 percent of total billed charges 280 476 50% of Eligible Charges SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC outpatient 560 448 BCBS Louisiana PPO 448 percent of total billed charges 308 476 80% of billed charge SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC outpatient 560 448 Cigna Commercial PPO 308 percent of total billed charges 308 476 55% of Billed Charges SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC inpatient 560 280 IMA of Louisiana Commercial PPO 476 percent of total billed charges 280 476 Inpatient Reimbursement at 85% of Billed Charges SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC outpatient 560 448 IMA of Louisiana Commercial PPO 476 percent of total billed charges 308 476 Reimbursement at 85% of billed charges SHUTTLE-RELAY SUTURE PASSING SYSTEM 272 RC outpatient 560 448 Aetna Commercial PPO 308 percent of total billed charges 308 476 55 of billed Charges TUR TUBING 272 RC inpatient 37.9 18.95 BCBS Louisiana PPO 18.95 percent of total billed charges 18.95 32.22 50% of Eligible Charges TUR TUBING 272 RC outpatient 37.9 30.32 BCBS Louisiana PPO 30.32 percent of total billed charges 20.85 32.22 80% of billed charge TUR TUBING 272 RC outpatient 37.9 30.32 Cigna Commercial PPO 20.85 percent of total billed charges 20.85 32.22 55% of Billed Charges TUR TUBING 272 RC inpatient 37.9 18.95 IMA of Louisiana Commercial PPO 32.22 percent of total billed charges 18.95 32.22 Inpatient Reimbursement at 85% of Billed Charges TUR TUBING 272 RC outpatient 37.9 30.32 IMA of Louisiana Commercial PPO 32.22 percent of total billed charges 20.85 32.22 Reimbursement at 85% of billed charges TUR TUBING 272 RC outpatient 37.9 30.32 Aetna Commercial PPO 20.85 percent of total billed charges 20.85 32.22 55 of billed Charges BLANKET WARMING 272 RC inpatient 251.58 125.79 BCBS Louisiana PPO 125.79 percent of total billed charges 125.79 213.84 50% of Eligible Charges BLANKET WARMING 272 RC outpatient 251.58 201.26 BCBS Louisiana PPO 201.26 percent of total billed charges 138.37 213.84 80% of billed charge BLANKET WARMING 272 RC outpatient 251.58 201.26 Cigna Commercial PPO 138.37 percent of total billed charges 138.37 213.84 55% of Billed Charges BLANKET WARMING 272 RC inpatient 251.58 125.79 IMA of Louisiana Commercial PPO 213.84 percent of total billed charges 125.79 213.84 Inpatient Reimbursement at 85% of Billed Charges BLANKET WARMING 272 RC outpatient 251.58 201.26 IMA of Louisiana Commercial PPO 213.84 percent of total billed charges 138.37 213.84 Reimbursement at 85% of billed charges BLANKET WARMING 272 RC outpatient 251.58 201.26 Aetna Commercial PPO 138.37 percent of total billed charges 138.37 213.84 55 of billed Charges SHOE POST-OP MALE XL STATMD 270 RC inpatient 22.68 11.34 BCBS Louisiana PPO 11.34 percent of total billed charges 11.34 19.28 50% of Eligible Charges SHOE POST-OP MALE XL STATMD 270 RC outpatient 22.68 18.14 BCBS Louisiana PPO 18.14 percent of total billed charges 12.47 19.28 80% of billed charge SHOE POST-OP MALE XL STATMD 270 RC outpatient 22.68 18.14 Cigna Commercial PPO 12.47 percent of total billed charges 12.47 19.28 55% of Billed Charges SHOE POST-OP MALE XL STATMD 270 RC inpatient 22.68 11.34 IMA of Louisiana Commercial PPO 19.28 percent of total billed charges 11.34 19.28 Inpatient Reimbursement at 85% of Billed Charges SHOE POST-OP MALE XL STATMD 270 RC outpatient 22.68 18.14 IMA of Louisiana Commercial PPO 19.28 percent of total billed charges 12.47 19.28 Reimbursement at 85% of billed charges SHOE POST-OP MALE XL STATMD 270 RC outpatient 22.68 18.14 Aetna Commercial PPO 12.47 percent of total billed charges 12.47 19.28 55 of billed Charges IV CATH 18G INTROCAN 272 RC inpatient 9.6 4.8 BCBS Louisiana PPO 4.8 percent of total billed charges 4.8 8.16 50% of Eligible Charges IV CATH 18G INTROCAN 272 RC outpatient 9.6 7.68 BCBS Louisiana PPO 7.68 percent of total billed charges 5.28 8.16 80% of billed charge IV CATH 18G INTROCAN 272 RC outpatient 9.6 7.68 Cigna Commercial PPO 5.28 percent of total billed charges 5.28 8.16 55% of Billed Charges IV CATH 18G INTROCAN 272 RC inpatient 9.6 4.8 IMA of Louisiana Commercial PPO 8.16 percent of total billed charges 4.8 8.16 Inpatient Reimbursement at 85% of Billed Charges IV CATH 18G INTROCAN 272 RC outpatient 9.6 7.68 IMA of Louisiana Commercial PPO 8.16 percent of total billed charges 5.28 8.16 Reimbursement at 85% of billed charges IV CATH 18G INTROCAN 272 RC outpatient 9.6 7.68 Aetna Commercial PPO 5.28 percent of total billed charges 5.28 8.16 55 of billed Charges ADAPTIC 3 X 8 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges ADAPTIC 3 X 8 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge ADAPTIC 3 X 8 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges ADAPTIC 3 X 8 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges ADAPTIC 3 X 8 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges ADAPTIC 3 X 8 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SUTURE NUROLON 5-0 PC-1 272 RC inpatient 201.18 100.59 BCBS Louisiana PPO 100.59 percent of total billed charges 100.59 171 50% of Eligible Charges SUTURE NUROLON 5-0 PC-1 272 RC outpatient 201.18 160.94 BCBS Louisiana PPO 160.94 percent of total billed charges 110.65 171 80% of billed charge SUTURE NUROLON 5-0 PC-1 272 RC outpatient 201.18 160.94 Cigna Commercial PPO 110.65 percent of total billed charges 110.65 171 55% of Billed Charges SUTURE NUROLON 5-0 PC-1 272 RC inpatient 201.18 100.59 IMA of Louisiana Commercial PPO 171 percent of total billed charges 100.59 171 Inpatient Reimbursement at 85% of Billed Charges SUTURE NUROLON 5-0 PC-1 272 RC outpatient 201.18 160.94 IMA of Louisiana Commercial PPO 171 percent of total billed charges 110.65 171 Reimbursement at 85% of billed charges SUTURE NUROLON 5-0 PC-1 272 RC outpatient 201.18 160.94 Aetna Commercial PPO 110.65 percent of total billed charges 110.65 171 55 of billed Charges NASAL CANNULA CRVD TIP 7' TU 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges NASAL CANNULA CRVD TIP 7' TU 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge NASAL CANNULA CRVD TIP 7' TU 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges NASAL CANNULA CRVD TIP 7' TU 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges NASAL CANNULA CRVD TIP 7' TU 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges NASAL CANNULA CRVD TIP 7' TU 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges SPIROMETER VOL INCENTIVE 270 RC inpatient 11.92 5.96 BCBS Louisiana PPO 5.96 percent of total billed charges 5.96 10.13 50% of Eligible Charges SPIROMETER VOL INCENTIVE 270 RC outpatient 11.92 9.54 BCBS Louisiana PPO 9.54 percent of total billed charges 6.56 10.13 80% of billed charge SPIROMETER VOL INCENTIVE 270 RC outpatient 11.92 9.54 Cigna Commercial PPO 6.56 percent of total billed charges 6.56 10.13 55% of Billed Charges SPIROMETER VOL INCENTIVE 270 RC inpatient 11.92 5.96 IMA of Louisiana Commercial PPO 10.13 percent of total billed charges 5.96 10.13 Inpatient Reimbursement at 85% of Billed Charges SPIROMETER VOL INCENTIVE 270 RC outpatient 11.92 9.54 IMA of Louisiana Commercial PPO 10.13 percent of total billed charges 6.56 10.13 Reimbursement at 85% of billed charges SPIROMETER VOL INCENTIVE 270 RC outpatient 11.92 9.54 Aetna Commercial PPO 6.56 percent of total billed charges 6.56 10.13 55 of billed Charges SYRINGE INSULIN 1CC 26GX1/2 272 RC inpatient 31.84 15.92 BCBS Louisiana PPO 15.92 percent of total billed charges 15.92 27.06 50% of Eligible Charges SYRINGE INSULIN 1CC 26GX1/2 272 RC outpatient 31.84 25.47 BCBS Louisiana PPO 25.47 percent of total billed charges 17.51 27.06 80% of billed charge SYRINGE INSULIN 1CC 26GX1/2 272 RC outpatient 31.84 25.47 Cigna Commercial PPO 17.51 percent of total billed charges 17.51 27.06 55% of Billed Charges SYRINGE INSULIN 1CC 26GX1/2 272 RC inpatient 31.84 15.92 IMA of Louisiana Commercial PPO 27.06 percent of total billed charges 15.92 27.06 Inpatient Reimbursement at 85% of Billed Charges SYRINGE INSULIN 1CC 26GX1/2 272 RC outpatient 31.84 25.47 IMA of Louisiana Commercial PPO 27.06 percent of total billed charges 17.51 27.06 Reimbursement at 85% of billed charges SYRINGE INSULIN 1CC 26GX1/2 272 RC outpatient 31.84 25.47 Aetna Commercial PPO 17.51 percent of total billed charges 17.51 27.06 55 of billed Charges MASK ANES W/INFL PORT ADLT LARGE 270 RC inpatient 890.63 445.32 BCBS Louisiana PPO 445.32 percent of total billed charges 445.32 757.04 50% of Eligible Charges MASK ANES W/INFL PORT ADLT LARGE 270 RC outpatient 890.63 712.5 BCBS Louisiana PPO 712.5 percent of total billed charges 489.85 757.04 80% of billed charge MASK ANES W/INFL PORT ADLT LARGE 270 RC outpatient 890.63 712.5 Cigna Commercial PPO 489.85 percent of total billed charges 489.85 757.04 55% of Billed Charges MASK ANES W/INFL PORT ADLT LARGE 270 RC inpatient 890.63 445.32 IMA of Louisiana Commercial PPO 757.04 percent of total billed charges 445.32 757.04 Inpatient Reimbursement at 85% of Billed Charges MASK ANES W/INFL PORT ADLT LARGE 270 RC outpatient 890.63 712.5 IMA of Louisiana Commercial PPO 757.04 percent of total billed charges 489.85 757.04 Reimbursement at 85% of billed charges MASK ANES W/INFL PORT ADLT LARGE 270 RC outpatient 890.63 712.5 Aetna Commercial PPO 489.85 percent of total billed charges 489.85 757.04 55 of billed Charges IMMOBILIZER UNIVERSAL KNEE 16 270 RC inpatient 100.1 50.05 BCBS Louisiana PPO 50.05 percent of total billed charges 50.05 85.09 50% of Eligible Charges IMMOBILIZER UNIVERSAL KNEE 16 270 RC outpatient 100.1 80.08 BCBS Louisiana PPO 80.08 percent of total billed charges 55.06 85.09 80% of billed charge IMMOBILIZER UNIVERSAL KNEE 16 270 RC outpatient 100.1 80.08 Cigna Commercial PPO 55.06 percent of total billed charges 55.06 85.09 55% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 16 270 RC inpatient 100.1 50.05 IMA of Louisiana Commercial PPO 85.09 percent of total billed charges 50.05 85.09 Inpatient Reimbursement at 85% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 16 270 RC outpatient 100.1 80.08 IMA of Louisiana Commercial PPO 85.09 percent of total billed charges 55.06 85.09 Reimbursement at 85% of billed charges IMMOBILIZER UNIVERSAL KNEE 16 270 RC outpatient 100.1 80.08 Aetna Commercial PPO 55.06 percent of total billed charges 55.06 85.09 55 of billed Charges IMMOBILIZER UNIVERSAL KNEE 22 270 RC inpatient 68.8 34.4 BCBS Louisiana PPO 34.4 percent of total billed charges 34.4 58.48 50% of Eligible Charges IMMOBILIZER UNIVERSAL KNEE 22 270 RC outpatient 68.8 55.04 BCBS Louisiana PPO 55.04 percent of total billed charges 37.84 58.48 80% of billed charge IMMOBILIZER UNIVERSAL KNEE 22 270 RC outpatient 68.8 55.04 Cigna Commercial PPO 37.84 percent of total billed charges 37.84 58.48 55% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 22 270 RC inpatient 68.8 34.4 IMA of Louisiana Commercial PPO 58.48 percent of total billed charges 34.4 58.48 Inpatient Reimbursement at 85% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 22 270 RC outpatient 68.8 55.04 IMA of Louisiana Commercial PPO 58.48 percent of total billed charges 37.84 58.48 Reimbursement at 85% of billed charges IMMOBILIZER UNIVERSAL KNEE 22 270 RC outpatient 68.8 55.04 Aetna Commercial PPO 37.84 percent of total billed charges 37.84 58.48 55 of billed Charges CATHETER 16FR LATEX FREE 272 RC inpatient 20.28 10.14 BCBS Louisiana PPO 10.14 percent of total billed charges 10.14 17.24 50% of Eligible Charges CATHETER 16FR LATEX FREE 272 RC outpatient 20.28 16.22 BCBS Louisiana PPO 16.22 percent of total billed charges 11.15 17.24 80% of billed charge CATHETER 16FR LATEX FREE 272 RC outpatient 20.28 16.22 Cigna Commercial PPO 11.15 percent of total billed charges 11.15 17.24 55% of Billed Charges CATHETER 16FR LATEX FREE 272 RC inpatient 20.28 10.14 IMA of Louisiana Commercial PPO 17.24 percent of total billed charges 10.14 17.24 Inpatient Reimbursement at 85% of Billed Charges CATHETER 16FR LATEX FREE 272 RC outpatient 20.28 16.22 IMA of Louisiana Commercial PPO 17.24 percent of total billed charges 11.15 17.24 Reimbursement at 85% of billed charges CATHETER 16FR LATEX FREE 272 RC outpatient 20.28 16.22 Aetna Commercial PPO 11.15 percent of total billed charges 11.15 17.24 55 of billed Charges SUTURE 1 VICRYL CT-1 CR J741D 272 RC inpatient 48.8 24.4 BCBS Louisiana PPO 24.4 percent of total billed charges 24.4 41.48 50% of Eligible Charges SUTURE 1 VICRYL CT-1 CR J741D 272 RC outpatient 48.8 39.04 BCBS Louisiana PPO 39.04 percent of total billed charges 26.84 41.48 80% of billed charge SUTURE 1 VICRYL CT-1 CR J741D 272 RC outpatient 48.8 39.04 Cigna Commercial PPO 26.84 percent of total billed charges 26.84 41.48 55% of Billed Charges SUTURE 1 VICRYL CT-1 CR J741D 272 RC inpatient 48.8 24.4 IMA of Louisiana Commercial PPO 41.48 percent of total billed charges 24.4 41.48 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 VICRYL CT-1 CR J741D 272 RC outpatient 48.8 39.04 IMA of Louisiana Commercial PPO 41.48 percent of total billed charges 26.84 41.48 Reimbursement at 85% of billed charges SUTURE 1 VICRYL CT-1 CR J741D 272 RC outpatient 48.8 39.04 Aetna Commercial PPO 26.84 percent of total billed charges 26.84 41.48 55 of billed Charges SUTURE 2-0 SILK PS 1588H 272 RC inpatient 15.28 7.64 BCBS Louisiana PPO 7.64 percent of total billed charges 7.64 12.99 50% of Eligible Charges SUTURE 2-0 SILK PS 1588H 272 RC outpatient 15.28 12.22 BCBS Louisiana PPO 12.22 percent of total billed charges 8.4 12.99 80% of billed charge SUTURE 2-0 SILK PS 1588H 272 RC outpatient 15.28 12.22 Cigna Commercial PPO 8.4 percent of total billed charges 8.4 12.99 55% of Billed Charges SUTURE 2-0 SILK PS 1588H 272 RC inpatient 15.28 7.64 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 7.64 12.99 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 SILK PS 1588H 272 RC outpatient 15.28 12.22 IMA of Louisiana Commercial PPO 12.99 percent of total billed charges 8.4 12.99 Reimbursement at 85% of billed charges SUTURE 2-0 SILK PS 1588H 272 RC outpatient 15.28 12.22 Aetna Commercial PPO 8.4 percent of total billed charges 8.4 12.99 55 of billed Charges CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC inpatient 26.24 13.12 BCBS Louisiana PPO 13.12 percent of total billed charges 13.12 22.3 50% of Eligible Charges CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC outpatient 26.24 20.99 BCBS Louisiana PPO 20.99 percent of total billed charges 14.43 22.3 80% of billed charge CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC outpatient 26.24 20.99 Cigna Commercial PPO 14.43 percent of total billed charges 14.43 22.3 55% of Billed Charges CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC inpatient 26.24 13.12 IMA of Louisiana Commercial PPO 22.3 percent of total billed charges 13.12 22.3 Inpatient Reimbursement at 85% of Billed Charges CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC outpatient 26.24 20.99 IMA of Louisiana Commercial PPO 22.3 percent of total billed charges 14.43 22.3 Reimbursement at 85% of billed charges CATHETER TRAY FOLEY 16 F 5CC W/URINE LF 272 RC outpatient 26.24 20.99 Aetna Commercial PPO 14.43 percent of total billed charges 14.43 22.3 55 of billed Charges CATHETER FOLEY 12 FR 272 RC inpatient 390.45 195.23 BCBS Louisiana PPO 195.23 percent of total billed charges 195.23 331.88 50% of Eligible Charges CATHETER FOLEY 12 FR 272 RC outpatient 390.45 312.36 BCBS Louisiana PPO 312.36 percent of total billed charges 214.75 331.88 80% of billed charge CATHETER FOLEY 12 FR 272 RC outpatient 390.45 312.36 Cigna Commercial PPO 214.75 percent of total billed charges 214.75 331.88 55% of Billed Charges CATHETER FOLEY 12 FR 272 RC inpatient 390.45 195.23 IMA of Louisiana Commercial PPO 331.88 percent of total billed charges 195.23 331.88 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY 12 FR 272 RC outpatient 390.45 312.36 IMA of Louisiana Commercial PPO 331.88 percent of total billed charges 214.75 331.88 Reimbursement at 85% of billed charges CATHETER FOLEY 12 FR 272 RC outpatient 390.45 312.36 Aetna Commercial PPO 214.75 percent of total billed charges 214.75 331.88 55 of billed Charges ACE FLEXMASTER 6 X 10 272 RC inpatient 132.65 66.33 BCBS Louisiana PPO 66.33 percent of total billed charges 66.33 112.75 50% of Eligible Charges ACE FLEXMASTER 6 X 10 272 RC outpatient 132.65 106.12 BCBS Louisiana PPO 106.12 percent of total billed charges 72.96 112.75 80% of billed charge ACE FLEXMASTER 6 X 10 272 RC outpatient 132.65 106.12 Cigna Commercial PPO 72.96 percent of total billed charges 72.96 112.75 55% of Billed Charges ACE FLEXMASTER 6 X 10 272 RC inpatient 132.65 66.33 IMA of Louisiana Commercial PPO 112.75 percent of total billed charges 66.33 112.75 Inpatient Reimbursement at 85% of Billed Charges ACE FLEXMASTER 6 X 10 272 RC outpatient 132.65 106.12 IMA of Louisiana Commercial PPO 112.75 percent of total billed charges 72.96 112.75 Reimbursement at 85% of billed charges ACE FLEXMASTER 6 X 10 272 RC outpatient 132.65 106.12 Aetna Commercial PPO 72.96 percent of total billed charges 72.96 112.75 55 of billed Charges BASIN WASH (GOLD) 270 RC inpatient 239.75 119.88 BCBS Louisiana PPO 119.88 percent of total billed charges 119.88 203.79 50% of Eligible Charges BASIN WASH (GOLD) 270 RC outpatient 239.75 191.8 BCBS Louisiana PPO 191.8 percent of total billed charges 131.86 203.79 80% of billed charge BASIN WASH (GOLD) 270 RC outpatient 239.75 191.8 Cigna Commercial PPO 131.86 percent of total billed charges 131.86 203.79 55% of Billed Charges BASIN WASH (GOLD) 270 RC inpatient 239.75 119.88 IMA of Louisiana Commercial PPO 203.79 percent of total billed charges 119.88 203.79 Inpatient Reimbursement at 85% of Billed Charges BASIN WASH (GOLD) 270 RC outpatient 239.75 191.8 IMA of Louisiana Commercial PPO 203.79 percent of total billed charges 131.86 203.79 Reimbursement at 85% of billed charges BASIN WASH (GOLD) 270 RC outpatient 239.75 191.8 Aetna Commercial PPO 131.86 percent of total billed charges 131.86 203.79 55 of billed Charges DRESSING XEROFORM STR 2 X 2 272 RC inpatient 8.8 4.4 BCBS Louisiana PPO 4.4 percent of total billed charges 4.4 7.48 50% of Eligible Charges DRESSING XEROFORM STR 2 X 2 272 RC outpatient 8.8 7.04 BCBS Louisiana PPO 7.04 percent of total billed charges 4.84 7.48 80% of billed charge DRESSING XEROFORM STR 2 X 2 272 RC outpatient 8.8 7.04 Cigna Commercial PPO 4.84 percent of total billed charges 4.84 7.48 55% of Billed Charges DRESSING XEROFORM STR 2 X 2 272 RC inpatient 8.8 4.4 IMA of Louisiana Commercial PPO 7.48 percent of total billed charges 4.4 7.48 Inpatient Reimbursement at 85% of Billed Charges DRESSING XEROFORM STR 2 X 2 272 RC outpatient 8.8 7.04 IMA of Louisiana Commercial PPO 7.48 percent of total billed charges 4.84 7.48 Reimbursement at 85% of billed charges DRESSING XEROFORM STR 2 X 2 272 RC outpatient 8.8 7.04 Aetna Commercial PPO 4.84 percent of total billed charges 4.84 7.48 55 of billed Charges SAW BLADE 2108-176-1 272 RC inpatient 94.5 47.25 BCBS Louisiana PPO 47.25 percent of total billed charges 47.25 80.33 50% of Eligible Charges SAW BLADE 2108-176-1 272 RC outpatient 94.5 75.6 BCBS Louisiana PPO 75.6 percent of total billed charges 51.98 80.33 80% of billed charge SAW BLADE 2108-176-1 272 RC outpatient 94.5 75.6 Cigna Commercial PPO 51.98 percent of total billed charges 51.98 80.33 55% of Billed Charges SAW BLADE 2108-176-1 272 RC inpatient 94.5 47.25 IMA of Louisiana Commercial PPO 80.33 percent of total billed charges 47.25 80.33 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-176-1 272 RC outpatient 94.5 75.6 IMA of Louisiana Commercial PPO 80.33 percent of total billed charges 51.98 80.33 Reimbursement at 85% of billed charges SAW BLADE 2108-176-1 272 RC outpatient 94.5 75.6 Aetna Commercial PPO 51.98 percent of total billed charges 51.98 80.33 55 of billed Charges SAW BLADE 2108-351 272 RC inpatient 82.84 41.42 BCBS Louisiana PPO 41.42 percent of total billed charges 41.42 70.41 50% of Eligible Charges SAW BLADE 2108-351 272 RC outpatient 82.84 66.27 BCBS Louisiana PPO 66.27 percent of total billed charges 45.56 70.41 80% of billed charge SAW BLADE 2108-351 272 RC outpatient 82.84 66.27 Cigna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55% of Billed Charges SAW BLADE 2108-351 272 RC inpatient 82.84 41.42 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 41.42 70.41 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-351 272 RC outpatient 82.84 66.27 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 45.56 70.41 Reimbursement at 85% of billed charges SAW BLADE 2108-351 272 RC outpatient 82.84 66.27 Aetna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55 of billed Charges SLING ARM ENVELOPE XL 270 RC inpatient 9.56 4.78 BCBS Louisiana PPO 4.78 percent of total billed charges 4.78 8.13 50% of Eligible Charges SLING ARM ENVELOPE XL 270 RC outpatient 9.56 7.65 BCBS Louisiana PPO 7.65 percent of total billed charges 5.26 8.13 80% of billed charge SLING ARM ENVELOPE XL 270 RC outpatient 9.56 7.65 Cigna Commercial PPO 5.26 percent of total billed charges 5.26 8.13 55% of Billed Charges SLING ARM ENVELOPE XL 270 RC inpatient 9.56 4.78 IMA of Louisiana Commercial PPO 8.13 percent of total billed charges 4.78 8.13 Inpatient Reimbursement at 85% of Billed Charges SLING ARM ENVELOPE XL 270 RC outpatient 9.56 7.65 IMA of Louisiana Commercial PPO 8.13 percent of total billed charges 5.26 8.13 Reimbursement at 85% of billed charges SLING ARM ENVELOPE XL 270 RC outpatient 9.56 7.65 Aetna Commercial PPO 5.26 percent of total billed charges 5.26 8.13 55 of billed Charges SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 22MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC inpatient 514.92 257.46 BCBS Louisiana PPO 257.46 percent of total billed charges 257.46 437.68 50% of Eligible Charges SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC outpatient 514.92 411.94 BCBS Louisiana PPO 411.94 percent of total billed charges 283.21 437.68 80% of billed charge SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC outpatient 514.92 411.94 Cigna Commercial PPO 283.21 percent of total billed charges 283.21 437.68 55% of Billed Charges SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC inpatient 514.92 257.46 IMA of Louisiana Commercial PPO 437.68 percent of total billed charges 257.46 437.68 Inpatient Reimbursement at 85% of Billed Charges SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC outpatient 514.92 411.94 IMA of Louisiana Commercial PPO 437.68 percent of total billed charges 283.21 437.68 Reimbursement at 85% of billed charges SENSTRAC MEDIUM GRANUFOAM - KCI 272 RC outpatient 514.92 411.94 Aetna Commercial PPO 283.21 percent of total billed charges 283.21 437.68 55 of billed Charges SUTURE 2-0 SILK TIE 18 272 RC inpatient 183.51 91.76 BCBS Louisiana PPO 91.76 percent of total billed charges 91.76 155.98 50% of Eligible Charges SUTURE 2-0 SILK TIE 18 272 RC outpatient 183.51 146.81 BCBS Louisiana PPO 146.81 percent of total billed charges 100.93 155.98 80% of billed charge SUTURE 2-0 SILK TIE 18 272 RC outpatient 183.51 146.81 Cigna Commercial PPO 100.93 percent of total billed charges 100.93 155.98 55% of Billed Charges SUTURE 2-0 SILK TIE 18 272 RC inpatient 183.51 91.76 IMA of Louisiana Commercial PPO 155.98 percent of total billed charges 91.76 155.98 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 SILK TIE 18 272 RC outpatient 183.51 146.81 IMA of Louisiana Commercial PPO 155.98 percent of total billed charges 100.93 155.98 Reimbursement at 85% of billed charges SUTURE 2-0 SILK TIE 18 272 RC outpatient 183.51 146.81 Aetna Commercial PPO 100.93 percent of total billed charges 100.93 155.98 55 of billed Charges CERVICAL COLLAR LG 270 RC inpatient 17.24 8.62 BCBS Louisiana PPO 8.62 percent of total billed charges 8.62 14.65 50% of Eligible Charges CERVICAL COLLAR LG 270 RC outpatient 17.24 13.79 BCBS Louisiana PPO 13.79 percent of total billed charges 9.48 14.65 80% of billed charge CERVICAL COLLAR LG 270 RC outpatient 17.24 13.79 Cigna Commercial PPO 9.48 percent of total billed charges 9.48 14.65 55% of Billed Charges CERVICAL COLLAR LG 270 RC inpatient 17.24 8.62 IMA of Louisiana Commercial PPO 14.65 percent of total billed charges 8.62 14.65 Inpatient Reimbursement at 85% of Billed Charges CERVICAL COLLAR LG 270 RC outpatient 17.24 13.79 IMA of Louisiana Commercial PPO 14.65 percent of total billed charges 9.48 14.65 Reimbursement at 85% of billed charges CERVICAL COLLAR LG 270 RC outpatient 17.24 13.79 Aetna Commercial PPO 9.48 percent of total billed charges 9.48 14.65 55 of billed Charges SPONGE NEURO 1/2 X 3 272 RC inpatient 21.44 10.72 BCBS Louisiana PPO 10.72 percent of total billed charges 10.72 18.22 50% of Eligible Charges SPONGE NEURO 1/2 X 3 272 RC outpatient 21.44 17.15 BCBS Louisiana PPO 17.15 percent of total billed charges 11.79 18.22 80% of billed charge SPONGE NEURO 1/2 X 3 272 RC outpatient 21.44 17.15 Cigna Commercial PPO 11.79 percent of total billed charges 11.79 18.22 55% of Billed Charges SPONGE NEURO 1/2 X 3 272 RC inpatient 21.44 10.72 IMA of Louisiana Commercial PPO 18.22 percent of total billed charges 10.72 18.22 Inpatient Reimbursement at 85% of Billed Charges SPONGE NEURO 1/2 X 3 272 RC outpatient 21.44 17.15 IMA of Louisiana Commercial PPO 18.22 percent of total billed charges 11.79 18.22 Reimbursement at 85% of billed charges SPONGE NEURO 1/2 X 3 272 RC outpatient 21.44 17.15 Aetna Commercial PPO 11.79 percent of total billed charges 11.79 18.22 55 of billed Charges TUBING EXTENSION SET- 272 RC inpatient 9.54 4.77 BCBS Louisiana PPO 4.77 percent of total billed charges 4.77 8.11 50% of Eligible Charges TUBING EXTENSION SET- 272 RC outpatient 9.54 7.63 BCBS Louisiana PPO 7.63 percent of total billed charges 5.25 8.11 80% of billed charge TUBING EXTENSION SET- 272 RC outpatient 9.54 7.63 Cigna Commercial PPO 5.25 percent of total billed charges 5.25 8.11 55% of Billed Charges TUBING EXTENSION SET- 272 RC inpatient 9.54 4.77 IMA of Louisiana Commercial PPO 8.11 percent of total billed charges 4.77 8.11 Inpatient Reimbursement at 85% of Billed Charges TUBING EXTENSION SET- 272 RC outpatient 9.54 7.63 IMA of Louisiana Commercial PPO 8.11 percent of total billed charges 5.25 8.11 Reimbursement at 85% of billed charges TUBING EXTENSION SET- 272 RC outpatient 9.54 7.63 Aetna Commercial PPO 5.25 percent of total billed charges 5.25 8.11 55 of billed Charges ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC inpatient 26.04 13.02 BCBS Louisiana PPO 13.02 percent of total billed charges 13.02 22.13 50% of Eligible Charges ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC outpatient 26.04 20.83 BCBS Louisiana PPO 20.83 percent of total billed charges 14.32 22.13 80% of billed charge ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC outpatient 26.04 20.83 Cigna Commercial PPO 14.32 percent of total billed charges 14.32 22.13 55% of Billed Charges ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC inpatient 26.04 13.02 IMA of Louisiana Commercial PPO 22.13 percent of total billed charges 13.02 22.13 Inpatient Reimbursement at 85% of Billed Charges ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC outpatient 26.04 20.83 IMA of Louisiana Commercial PPO 22.13 percent of total billed charges 14.32 22.13 Reimbursement at 85% of billed charges ABDOMINAL BINDER 3 PANEL 30-45 UNI 270 RC outpatient 26.04 20.83 Aetna Commercial PPO 14.32 percent of total billed charges 14.32 22.13 55 of billed Charges BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC inpatient 7 3.5 BCBS Louisiana PPO 3.5 percent of total billed charges 3.5 5.95 50% of Eligible Charges BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC outpatient 7 5.6 BCBS Louisiana PPO 5.6 percent of total billed charges 3.85 5.95 80% of billed charge BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC outpatient 7 5.6 Cigna Commercial PPO 3.85 percent of total billed charges 3.85 5.95 55% of Billed Charges BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC inpatient 7 3.5 IMA of Louisiana Commercial PPO 5.95 percent of total billed charges 3.5 5.95 Inpatient Reimbursement at 85% of Billed Charges BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC outpatient 7 5.6 IMA of Louisiana Commercial PPO 5.95 percent of total billed charges 3.85 5.95 Reimbursement at 85% of billed charges BABY WIPE-ADLT/FLUSHABLE UNSECENTED 270 RC outpatient 7 5.6 Aetna Commercial PPO 3.85 percent of total billed charges 3.85 5.95 55 of billed Charges CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC inpatient 1250 625 BCBS Louisiana PPO 625 percent of total billed charges 625 1062.5 50% of Eligible Charges CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC outpatient 1250 1000 BCBS Louisiana PPO 1000 percent of total billed charges 462.5 1062.5 80% of billed charge CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC outpatient 1250 1000 Cigna Commercial PPO 725 percent of total billed charges 462.5 1062.5 58% of Billed Charges/$500 Threshold CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC inpatient 1250 625 IMA of Louisiana Commercial PPO 1062.5 percent of total billed charges 625 1062.5 Inpatient Reimbursement at 85% of Billed Charges CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC outpatient 1250 1000 IMA of Louisiana Commercial PPO 1062.5 percent of total billed charges 462.5 1062.5 Reimbursement at 85% of billed charges CEMENT #2 WRIGHT CMW 20G C1713 HCPCS 278 RC outpatient 1250 1000 Aetna Commercial PPO 462.5 percent of total billed charges 462.5 1062.5 37% Of Billed Charges 2000 POLAR CARE PAD 270 RC inpatient 77.96 38.98 BCBS Louisiana PPO 38.98 percent of total billed charges 38.98 66.27 50% of Eligible Charges POLAR CARE PAD 270 RC outpatient 77.96 62.37 BCBS Louisiana PPO 62.37 percent of total billed charges 42.88 66.27 80% of billed charge POLAR CARE PAD 270 RC outpatient 77.96 62.37 Cigna Commercial PPO 42.88 percent of total billed charges 42.88 66.27 55% of Billed Charges POLAR CARE PAD 270 RC inpatient 77.96 38.98 IMA of Louisiana Commercial PPO 66.27 percent of total billed charges 38.98 66.27 Inpatient Reimbursement at 85% of Billed Charges POLAR CARE PAD 270 RC outpatient 77.96 62.37 IMA of Louisiana Commercial PPO 66.27 percent of total billed charges 42.88 66.27 Reimbursement at 85% of billed charges POLAR CARE PAD 270 RC outpatient 77.96 62.37 Aetna Commercial PPO 42.88 percent of total billed charges 42.88 66.27 55 of billed Charges "VIA STARTER KIT, 7 DAY KIT" 272 RC inpatient 905 452.5 BCBS Louisiana PPO 452.5 percent of total billed charges 452.5 769.25 50% of Eligible Charges "VIA STARTER KIT, 7 DAY KIT" 272 RC outpatient 905 724 BCBS Louisiana PPO 724 percent of total billed charges 497.75 769.25 80% of billed charge "VIA STARTER KIT, 7 DAY KIT" 272 RC outpatient 905 724 Cigna Commercial PPO 497.75 percent of total billed charges 497.75 769.25 55% of Billed Charges "VIA STARTER KIT, 7 DAY KIT" 272 RC inpatient 905 452.5 IMA of Louisiana Commercial PPO 769.25 percent of total billed charges 452.5 769.25 Inpatient Reimbursement at 85% of Billed Charges "VIA STARTER KIT, 7 DAY KIT" 272 RC outpatient 905 724 IMA of Louisiana Commercial PPO 769.25 percent of total billed charges 497.75 769.25 Reimbursement at 85% of billed charges "VIA STARTER KIT, 7 DAY KIT" 272 RC outpatient 905 724 Aetna Commercial PPO 497.75 percent of total billed charges 497.75 769.25 55 of billed Charges PREP (DURAPREP) 272 RC inpatient 17.04 8.52 BCBS Louisiana PPO 8.52 percent of total billed charges 8.52 14.48 50% of Eligible Charges PREP (DURAPREP) 272 RC outpatient 17.04 13.63 BCBS Louisiana PPO 13.63 percent of total billed charges 9.37 14.48 80% of billed charge PREP (DURAPREP) 272 RC outpatient 17.04 13.63 Cigna Commercial PPO 9.37 percent of total billed charges 9.37 14.48 55% of Billed Charges PREP (DURAPREP) 272 RC inpatient 17.04 8.52 IMA of Louisiana Commercial PPO 14.48 percent of total billed charges 8.52 14.48 Inpatient Reimbursement at 85% of Billed Charges PREP (DURAPREP) 272 RC outpatient 17.04 13.63 IMA of Louisiana Commercial PPO 14.48 percent of total billed charges 9.37 14.48 Reimbursement at 85% of billed charges PREP (DURAPREP) 272 RC outpatient 17.04 13.63 Aetna Commercial PPO 9.37 percent of total billed charges 9.37 14.48 55 of billed Charges SUTURE LASSO 25 DEGREE RIGHT 272 RC inpatient 507.5 253.75 BCBS Louisiana PPO 253.75 percent of total billed charges 253.75 431.38 50% of Eligible Charges SUTURE LASSO 25 DEGREE RIGHT 272 RC outpatient 507.5 406 BCBS Louisiana PPO 406 percent of total billed charges 279.13 431.38 80% of billed charge SUTURE LASSO 25 DEGREE RIGHT 272 RC outpatient 507.5 406 Cigna Commercial PPO 279.13 percent of total billed charges 279.13 431.38 55% of Billed Charges SUTURE LASSO 25 DEGREE RIGHT 272 RC inpatient 507.5 253.75 IMA of Louisiana Commercial PPO 431.38 percent of total billed charges 253.75 431.38 Inpatient Reimbursement at 85% of Billed Charges SUTURE LASSO 25 DEGREE RIGHT 272 RC outpatient 507.5 406 IMA of Louisiana Commercial PPO 431.38 percent of total billed charges 279.13 431.38 Reimbursement at 85% of billed charges SUTURE LASSO 25 DEGREE RIGHT 272 RC outpatient 507.5 406 Aetna Commercial PPO 279.13 percent of total billed charges 279.13 431.38 55 of billed Charges ACTICOAT DRESSING 4X10 272 RC inpatient 185.85 92.93 BCBS Louisiana PPO 92.93 percent of total billed charges 92.93 157.97 50% of Eligible Charges ACTICOAT DRESSING 4X10 272 RC outpatient 185.85 148.68 BCBS Louisiana PPO 148.68 percent of total billed charges 102.22 157.97 80% of billed charge ACTICOAT DRESSING 4X10 272 RC outpatient 185.85 148.68 Cigna Commercial PPO 102.22 percent of total billed charges 102.22 157.97 55% of Billed Charges ACTICOAT DRESSING 4X10 272 RC inpatient 185.85 92.93 IMA of Louisiana Commercial PPO 157.97 percent of total billed charges 92.93 157.97 Inpatient Reimbursement at 85% of Billed Charges ACTICOAT DRESSING 4X10 272 RC outpatient 185.85 148.68 IMA of Louisiana Commercial PPO 157.97 percent of total billed charges 102.22 157.97 Reimbursement at 85% of billed charges ACTICOAT DRESSING 4X10 272 RC outpatient 185.85 148.68 Aetna Commercial PPO 102.22 percent of total billed charges 102.22 157.97 55 of billed Charges SAW BLADE 2108-382 272 RC inpatient 82.84 41.42 BCBS Louisiana PPO 41.42 percent of total billed charges 41.42 70.41 50% of Eligible Charges SAW BLADE 2108-382 272 RC outpatient 82.84 66.27 BCBS Louisiana PPO 66.27 percent of total billed charges 45.56 70.41 80% of billed charge SAW BLADE 2108-382 272 RC outpatient 82.84 66.27 Cigna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55% of Billed Charges SAW BLADE 2108-382 272 RC inpatient 82.84 41.42 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 41.42 70.41 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-382 272 RC outpatient 82.84 66.27 IMA of Louisiana Commercial PPO 70.41 percent of total billed charges 45.56 70.41 Reimbursement at 85% of billed charges SAW BLADE 2108-382 272 RC outpatient 82.84 66.27 Aetna Commercial PPO 45.56 percent of total billed charges 45.56 70.41 55 of billed Charges SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 14MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 CAST FOAM ELEVATOR - DOG HOUSE 270 RC inpatient 103.6 51.8 BCBS Louisiana PPO 51.8 percent of total billed charges 51.8 88.06 50% of Eligible Charges CAST FOAM ELEVATOR - DOG HOUSE 270 RC outpatient 103.6 82.88 BCBS Louisiana PPO 82.88 percent of total billed charges 56.98 88.06 80% of billed charge CAST FOAM ELEVATOR - DOG HOUSE 270 RC outpatient 103.6 82.88 Cigna Commercial PPO 56.98 percent of total billed charges 56.98 88.06 55% of Billed Charges CAST FOAM ELEVATOR - DOG HOUSE 270 RC inpatient 103.6 51.8 IMA of Louisiana Commercial PPO 88.06 percent of total billed charges 51.8 88.06 Inpatient Reimbursement at 85% of Billed Charges CAST FOAM ELEVATOR - DOG HOUSE 270 RC outpatient 103.6 82.88 IMA of Louisiana Commercial PPO 88.06 percent of total billed charges 56.98 88.06 Reimbursement at 85% of billed charges CAST FOAM ELEVATOR - DOG HOUSE 270 RC outpatient 103.6 82.88 Aetna Commercial PPO 56.98 percent of total billed charges 56.98 88.06 55 of billed Charges SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 26MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 32MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 BUR #9MH30 M-8 9CM 272 RC inpatient 289.63 144.82 BCBS Louisiana PPO 144.82 percent of total billed charges 144.82 246.19 50% of Eligible Charges BUR #9MH30 M-8 9CM 272 RC outpatient 289.63 231.7 BCBS Louisiana PPO 231.7 percent of total billed charges 159.3 246.19 80% of billed charge BUR #9MH30 M-8 9CM 272 RC outpatient 289.63 231.7 Cigna Commercial PPO 159.3 percent of total billed charges 159.3 246.19 55% of Billed Charges BUR #9MH30 M-8 9CM 272 RC inpatient 289.63 144.82 IMA of Louisiana Commercial PPO 246.19 percent of total billed charges 144.82 246.19 Inpatient Reimbursement at 85% of Billed Charges BUR #9MH30 M-8 9CM 272 RC outpatient 289.63 231.7 IMA of Louisiana Commercial PPO 246.19 percent of total billed charges 159.3 246.19 Reimbursement at 85% of billed charges BUR #9MH30 M-8 9CM 272 RC outpatient 289.63 231.7 Aetna Commercial PPO 159.3 percent of total billed charges 159.3 246.19 55 of billed Charges SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 18MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 SPONGE KITTNER 9/16 X 1/4 272 RC inpatient 10.71 5.36 BCBS Louisiana PPO 5.36 percent of total billed charges 5.36 9.1 50% of Eligible Charges SPONGE KITTNER 9/16 X 1/4 272 RC outpatient 10.71 8.57 BCBS Louisiana PPO 8.57 percent of total billed charges 5.89 9.1 80% of billed charge SPONGE KITTNER 9/16 X 1/4 272 RC outpatient 10.71 8.57 Cigna Commercial PPO 5.89 percent of total billed charges 5.89 9.1 55% of Billed Charges SPONGE KITTNER 9/16 X 1/4 272 RC inpatient 10.71 5.36 IMA of Louisiana Commercial PPO 9.1 percent of total billed charges 5.36 9.1 Inpatient Reimbursement at 85% of Billed Charges SPONGE KITTNER 9/16 X 1/4 272 RC outpatient 10.71 8.57 IMA of Louisiana Commercial PPO 9.1 percent of total billed charges 5.89 9.1 Reimbursement at 85% of billed charges SPONGE KITTNER 9/16 X 1/4 272 RC outpatient 10.71 8.57 Aetna Commercial PPO 5.89 percent of total billed charges 5.89 9.1 55 of billed Charges SPONGE LAP 272 RC inpatient 6.38 3.19 BCBS Louisiana PPO 3.19 percent of total billed charges 3.19 5.42 50% of Eligible Charges SPONGE LAP 272 RC outpatient 6.38 5.1 BCBS Louisiana PPO 5.1 percent of total billed charges 3.51 5.42 80% of billed charge SPONGE LAP 272 RC outpatient 6.38 5.1 Cigna Commercial PPO 3.51 percent of total billed charges 3.51 5.42 55% of Billed Charges SPONGE LAP 272 RC inpatient 6.38 3.19 IMA of Louisiana Commercial PPO 5.42 percent of total billed charges 3.19 5.42 Inpatient Reimbursement at 85% of Billed Charges SPONGE LAP 272 RC outpatient 6.38 5.1 IMA of Louisiana Commercial PPO 5.42 percent of total billed charges 3.51 5.42 Reimbursement at 85% of billed charges SPONGE LAP 272 RC outpatient 6.38 5.1 Aetna Commercial PPO 3.51 percent of total billed charges 3.51 5.42 55 of billed Charges COTTONOID 3/4 X 3/4 272 RC inpatient 31.32 15.66 BCBS Louisiana PPO 15.66 percent of total billed charges 15.66 26.62 50% of Eligible Charges COTTONOID 3/4 X 3/4 272 RC outpatient 31.32 25.06 BCBS Louisiana PPO 25.06 percent of total billed charges 17.23 26.62 80% of billed charge COTTONOID 3/4 X 3/4 272 RC outpatient 31.32 25.06 Cigna Commercial PPO 17.23 percent of total billed charges 17.23 26.62 55% of Billed Charges COTTONOID 3/4 X 3/4 272 RC inpatient 31.32 15.66 IMA of Louisiana Commercial PPO 26.62 percent of total billed charges 15.66 26.62 Inpatient Reimbursement at 85% of Billed Charges COTTONOID 3/4 X 3/4 272 RC outpatient 31.32 25.06 IMA of Louisiana Commercial PPO 26.62 percent of total billed charges 17.23 26.62 Reimbursement at 85% of billed charges COTTONOID 3/4 X 3/4 272 RC outpatient 31.32 25.06 Aetna Commercial PPO 17.23 percent of total billed charges 17.23 26.62 55 of billed Charges STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC inpatient 27.64 13.82 BCBS Louisiana PPO 13.82 percent of total billed charges 13.82 23.49 50% of Eligible Charges STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC outpatient 27.64 22.11 BCBS Louisiana PPO 22.11 percent of total billed charges 15.2 23.49 80% of billed charge STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC outpatient 27.64 22.11 Cigna Commercial PPO 15.2 percent of total billed charges 15.2 23.49 55% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC inpatient 27.64 13.82 IMA of Louisiana Commercial PPO 23.49 percent of total billed charges 13.82 23.49 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC outpatient 27.64 22.11 IMA of Louisiana Commercial PPO 23.49 percent of total billed charges 15.2 23.49 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM REG THIGH LG 270 RC outpatient 27.64 22.11 Aetna Commercial PPO 15.2 percent of total billed charges 15.2 23.49 55 of billed Charges TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC inpatient 431.52 215.76 BCBS Louisiana PPO 215.76 percent of total billed charges 215.76 366.79 50% of Eligible Charges TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC outpatient 431.52 345.22 BCBS Louisiana PPO 345.22 percent of total billed charges 237.34 366.79 80% of billed charge TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC outpatient 431.52 345.22 Cigna Commercial PPO 237.34 percent of total billed charges 237.34 366.79 55% of Billed Charges TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC inpatient 431.52 215.76 IMA of Louisiana Commercial PPO 366.79 percent of total billed charges 215.76 366.79 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC outpatient 431.52 345.22 IMA of Louisiana Commercial PPO 366.79 percent of total billed charges 237.34 366.79 Reimbursement at 85% of billed charges TOURNIQUET 30'' DISPOSABLE STRYKER 272 RC outpatient 431.52 345.22 Aetna Commercial PPO 237.34 percent of total billed charges 237.34 366.79 55 of billed Charges STYLET FLEX TIP 14 FR 272 RC inpatient 168.35 84.18 BCBS Louisiana PPO 84.18 percent of total billed charges 84.18 143.1 50% of Eligible Charges STYLET FLEX TIP 14 FR 272 RC outpatient 168.35 134.68 BCBS Louisiana PPO 134.68 percent of total billed charges 92.59 143.1 80% of billed charge STYLET FLEX TIP 14 FR 272 RC outpatient 168.35 134.68 Cigna Commercial PPO 92.59 percent of total billed charges 92.59 143.1 55% of Billed Charges STYLET FLEX TIP 14 FR 272 RC inpatient 168.35 84.18 IMA of Louisiana Commercial PPO 143.1 percent of total billed charges 84.18 143.1 Inpatient Reimbursement at 85% of Billed Charges STYLET FLEX TIP 14 FR 272 RC outpatient 168.35 134.68 IMA of Louisiana Commercial PPO 143.1 percent of total billed charges 92.59 143.1 Reimbursement at 85% of billed charges STYLET FLEX TIP 14 FR 272 RC outpatient 168.35 134.68 Aetna Commercial PPO 92.59 percent of total billed charges 92.59 143.1 55 of billed Charges RANGER BLOOD/FLUID WARMER CASSETTE 270 RC inpatient 41.31 20.66 BCBS Louisiana PPO 20.66 percent of total billed charges 20.66 35.11 50% of Eligible Charges RANGER BLOOD/FLUID WARMER CASSETTE 270 RC outpatient 41.31 33.05 BCBS Louisiana PPO 33.05 percent of total billed charges 22.72 35.11 80% of billed charge RANGER BLOOD/FLUID WARMER CASSETTE 270 RC outpatient 41.31 33.05 Cigna Commercial PPO 22.72 percent of total billed charges 22.72 35.11 55% of Billed Charges RANGER BLOOD/FLUID WARMER CASSETTE 270 RC inpatient 41.31 20.66 IMA of Louisiana Commercial PPO 35.11 percent of total billed charges 20.66 35.11 Inpatient Reimbursement at 85% of Billed Charges RANGER BLOOD/FLUID WARMER CASSETTE 270 RC outpatient 41.31 33.05 IMA of Louisiana Commercial PPO 35.11 percent of total billed charges 22.72 35.11 Reimbursement at 85% of billed charges RANGER BLOOD/FLUID WARMER CASSETTE 270 RC outpatient 41.31 33.05 Aetna Commercial PPO 22.72 percent of total billed charges 22.72 35.11 55 of billed Charges PICC LINE CAP - MAXPLUS 272 RC inpatient 642.78 321.39 BCBS Louisiana PPO 321.39 percent of total billed charges 321.39 546.36 50% of Eligible Charges PICC LINE CAP - MAXPLUS 272 RC outpatient 642.78 514.22 BCBS Louisiana PPO 514.22 percent of total billed charges 353.53 546.36 80% of billed charge PICC LINE CAP - MAXPLUS 272 RC outpatient 642.78 514.22 Cigna Commercial PPO 353.53 percent of total billed charges 353.53 546.36 55% of Billed Charges PICC LINE CAP - MAXPLUS 272 RC inpatient 642.78 321.39 IMA of Louisiana Commercial PPO 546.36 percent of total billed charges 321.39 546.36 Inpatient Reimbursement at 85% of Billed Charges PICC LINE CAP - MAXPLUS 272 RC outpatient 642.78 514.22 IMA of Louisiana Commercial PPO 546.36 percent of total billed charges 353.53 546.36 Reimbursement at 85% of billed charges PICC LINE CAP - MAXPLUS 272 RC outpatient 642.78 514.22 Aetna Commercial PPO 353.53 percent of total billed charges 353.53 546.36 55 of billed Charges SUTURE 0 VICRYL CT-1 J260H 272 RC inpatient 6.4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 3.2 5.44 50% of Eligible Charges SUTURE 0 VICRYL CT-1 J260H 272 RC outpatient 6.4 5.12 BCBS Louisiana PPO 5.12 percent of total billed charges 3.52 5.44 80% of billed charge SUTURE 0 VICRYL CT-1 J260H 272 RC outpatient 6.4 5.12 Cigna Commercial PPO 3.52 percent of total billed charges 3.52 5.44 55% of Billed Charges SUTURE 0 VICRYL CT-1 J260H 272 RC inpatient 6.4 3.2 IMA of Louisiana Commercial PPO 5.44 percent of total billed charges 3.2 5.44 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL CT-1 J260H 272 RC outpatient 6.4 5.12 IMA of Louisiana Commercial PPO 5.44 percent of total billed charges 3.52 5.44 Reimbursement at 85% of billed charges SUTURE 0 VICRYL CT-1 J260H 272 RC outpatient 6.4 5.12 Aetna Commercial PPO 3.52 percent of total billed charges 3.52 5.44 55 of billed Charges SUTURE 2 ETHIBOND V-37 MX69G 272 RC inpatient 65.96 32.98 BCBS Louisiana PPO 32.98 percent of total billed charges 32.98 56.07 50% of Eligible Charges SUTURE 2 ETHIBOND V-37 MX69G 272 RC outpatient 65.96 52.77 BCBS Louisiana PPO 52.77 percent of total billed charges 36.28 56.07 80% of billed charge SUTURE 2 ETHIBOND V-37 MX69G 272 RC outpatient 65.96 52.77 Cigna Commercial PPO 36.28 percent of total billed charges 36.28 56.07 55% of Billed Charges SUTURE 2 ETHIBOND V-37 MX69G 272 RC inpatient 65.96 32.98 IMA of Louisiana Commercial PPO 56.07 percent of total billed charges 32.98 56.07 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2 ETHIBOND V-37 MX69G 272 RC outpatient 65.96 52.77 IMA of Louisiana Commercial PPO 56.07 percent of total billed charges 36.28 56.07 Reimbursement at 85% of billed charges SUTURE 2 ETHIBOND V-37 MX69G 272 RC outpatient 65.96 52.77 Aetna Commercial PPO 36.28 percent of total billed charges 36.28 56.07 55 of billed Charges SUTURE 9-0 ETHILON BV100-4 272 RC inpatient 96.16 48.08 BCBS Louisiana PPO 48.08 percent of total billed charges 48.08 81.74 50% of Eligible Charges SUTURE 9-0 ETHILON BV100-4 272 RC outpatient 96.16 76.93 BCBS Louisiana PPO 76.93 percent of total billed charges 52.89 81.74 80% of billed charge SUTURE 9-0 ETHILON BV100-4 272 RC outpatient 96.16 76.93 Cigna Commercial PPO 52.89 percent of total billed charges 52.89 81.74 55% of Billed Charges SUTURE 9-0 ETHILON BV100-4 272 RC inpatient 96.16 48.08 IMA of Louisiana Commercial PPO 81.74 percent of total billed charges 48.08 81.74 Inpatient Reimbursement at 85% of Billed Charges SUTURE 9-0 ETHILON BV100-4 272 RC outpatient 96.16 76.93 IMA of Louisiana Commercial PPO 81.74 percent of total billed charges 52.89 81.74 Reimbursement at 85% of billed charges SUTURE 9-0 ETHILON BV100-4 272 RC outpatient 96.16 76.93 Aetna Commercial PPO 52.89 percent of total billed charges 52.89 81.74 55 of billed Charges SUTURE 2-0 ETHILON PS-2 593H 272 RC inpatient 16.56 8.28 BCBS Louisiana PPO 8.28 percent of total billed charges 8.28 14.08 50% of Eligible Charges SUTURE 2-0 ETHILON PS-2 593H 272 RC outpatient 16.56 13.25 BCBS Louisiana PPO 13.25 percent of total billed charges 9.11 14.08 80% of billed charge SUTURE 2-0 ETHILON PS-2 593H 272 RC outpatient 16.56 13.25 Cigna Commercial PPO 9.11 percent of total billed charges 9.11 14.08 55% of Billed Charges SUTURE 2-0 ETHILON PS-2 593H 272 RC inpatient 16.56 8.28 IMA of Louisiana Commercial PPO 14.08 percent of total billed charges 8.28 14.08 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 ETHILON PS-2 593H 272 RC outpatient 16.56 13.25 IMA of Louisiana Commercial PPO 14.08 percent of total billed charges 9.11 14.08 Reimbursement at 85% of billed charges SUTURE 2-0 ETHILON PS-2 593H 272 RC outpatient 16.56 13.25 Aetna Commercial PPO 9.11 percent of total billed charges 9.11 14.08 55 of billed Charges SUTURE 2-0 VICRYL CT-2 J269H 272 RC inpatient 6.8 3.4 BCBS Louisiana PPO 3.4 percent of total billed charges 3.4 5.78 50% of Eligible Charges SUTURE 2-0 VICRYL CT-2 J269H 272 RC outpatient 6.8 5.44 BCBS Louisiana PPO 5.44 percent of total billed charges 3.74 5.78 80% of billed charge SUTURE 2-0 VICRYL CT-2 J269H 272 RC outpatient 6.8 5.44 Cigna Commercial PPO 3.74 percent of total billed charges 3.74 5.78 55% of Billed Charges SUTURE 2-0 VICRYL CT-2 J269H 272 RC inpatient 6.8 3.4 IMA of Louisiana Commercial PPO 5.78 percent of total billed charges 3.4 5.78 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL CT-2 J269H 272 RC outpatient 6.8 5.44 IMA of Louisiana Commercial PPO 5.78 percent of total billed charges 3.74 5.78 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL CT-2 J269H 272 RC outpatient 6.8 5.44 Aetna Commercial PPO 3.74 percent of total billed charges 3.74 5.78 55 of billed Charges SUTURE 3-0 VICRYL SH J416H 272 RC inpatient 6.36 3.18 BCBS Louisiana PPO 3.18 percent of total billed charges 3.18 5.41 50% of Eligible Charges SUTURE 3-0 VICRYL SH J416H 272 RC outpatient 6.36 5.09 BCBS Louisiana PPO 5.09 percent of total billed charges 3.5 5.41 80% of billed charge SUTURE 3-0 VICRYL SH J416H 272 RC outpatient 6.36 5.09 Cigna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55% of Billed Charges SUTURE 3-0 VICRYL SH J416H 272 RC inpatient 6.36 3.18 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.18 5.41 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 VICRYL SH J416H 272 RC outpatient 6.36 5.09 IMA of Louisiana Commercial PPO 5.41 percent of total billed charges 3.5 5.41 Reimbursement at 85% of billed charges SUTURE 3-0 VICRYL SH J416H 272 RC outpatient 6.36 5.09 Aetna Commercial PPO 3.5 percent of total billed charges 3.5 5.41 55 of billed Charges SUTURE 4-0 MERSILENE P-3 R691G 272 RC inpatient 174.93 87.47 BCBS Louisiana PPO 87.47 percent of total billed charges 87.47 148.69 50% of Eligible Charges SUTURE 4-0 MERSILENE P-3 R691G 272 RC outpatient 174.93 139.94 BCBS Louisiana PPO 139.94 percent of total billed charges 96.21 148.69 80% of billed charge SUTURE 4-0 MERSILENE P-3 R691G 272 RC outpatient 174.93 139.94 Cigna Commercial PPO 96.21 percent of total billed charges 96.21 148.69 55% of Billed Charges SUTURE 4-0 MERSILENE P-3 R691G 272 RC inpatient 174.93 87.47 IMA of Louisiana Commercial PPO 148.69 percent of total billed charges 87.47 148.69 Inpatient Reimbursement at 85% of Billed Charges SUTURE 4-0 MERSILENE P-3 R691G 272 RC outpatient 174.93 139.94 IMA of Louisiana Commercial PPO 148.69 percent of total billed charges 96.21 148.69 Reimbursement at 85% of billed charges SUTURE 4-0 MERSILENE P-3 R691G 272 RC outpatient 174.93 139.94 Aetna Commercial PPO 96.21 percent of total billed charges 96.21 148.69 55 of billed Charges STOCKING KNEE - SM LONG 270 RC inpatient 120.54 60.27 BCBS Louisiana PPO 60.27 percent of total billed charges 60.27 102.46 50% of Eligible Charges STOCKING KNEE - SM LONG 270 RC outpatient 120.54 96.43 BCBS Louisiana PPO 96.43 percent of total billed charges 66.3 102.46 80% of billed charge STOCKING KNEE - SM LONG 270 RC outpatient 120.54 96.43 Cigna Commercial PPO 66.3 percent of total billed charges 66.3 102.46 55% of Billed Charges STOCKING KNEE - SM LONG 270 RC inpatient 120.54 60.27 IMA of Louisiana Commercial PPO 102.46 percent of total billed charges 60.27 102.46 Inpatient Reimbursement at 85% of Billed Charges STOCKING KNEE - SM LONG 270 RC outpatient 120.54 96.43 IMA of Louisiana Commercial PPO 102.46 percent of total billed charges 66.3 102.46 Reimbursement at 85% of billed charges STOCKING KNEE - SM LONG 270 RC outpatient 120.54 96.43 Aetna Commercial PPO 66.3 percent of total billed charges 66.3 102.46 55 of billed Charges SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC inpatient 24.56 12.28 BCBS Louisiana PPO 12.28 percent of total billed charges 12.28 20.88 50% of Eligible Charges SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC outpatient 24.56 19.65 BCBS Louisiana PPO 19.65 percent of total billed charges 13.51 20.88 80% of billed charge SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC outpatient 24.56 19.65 Cigna Commercial PPO 13.51 percent of total billed charges 13.51 20.88 55% of Billed Charges SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC inpatient 24.56 12.28 IMA of Louisiana Commercial PPO 20.88 percent of total billed charges 12.28 20.88 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC outpatient 24.56 19.65 IMA of Louisiana Commercial PPO 20.88 percent of total billed charges 13.51 20.88 Reimbursement at 85% of billed charges SUTURE 5-0 MONOCRYL PS-2 Y495G 272 RC outpatient 24.56 19.65 Aetna Commercial PPO 13.51 percent of total billed charges 13.51 20.88 55 of billed Charges SYRINGE 10CC LL 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE 10CC LL 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE 10CC LL 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE 10CC LL 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 10CC LL 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE 10CC LL 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SYRINGE 20CC LL 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE 20CC LL 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE 20CC LL 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE 20CC LL 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 20CC LL 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE 20CC LL 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges SYRINGE 5CC 21 X 1 272 RC inpatient 3 1.5 BCBS Louisiana PPO 1.5 percent of total billed charges 1.5 2.55 50% of Eligible Charges SYRINGE 5CC 21 X 1 272 RC outpatient 3 2.4 BCBS Louisiana PPO 2.4 percent of total billed charges 1.65 2.55 80% of billed charge SYRINGE 5CC 21 X 1 272 RC outpatient 3 2.4 Cigna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55% of Billed Charges SYRINGE 5CC 21 X 1 272 RC inpatient 3 1.5 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.5 2.55 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 5CC 21 X 1 272 RC outpatient 3 2.4 IMA of Louisiana Commercial PPO 2.55 percent of total billed charges 1.65 2.55 Reimbursement at 85% of billed charges SYRINGE 5CC 21 X 1 272 RC outpatient 3 2.4 Aetna Commercial PPO 1.65 percent of total billed charges 1.65 2.55 55 of billed Charges TAPE DURAPORE SILK 3 270 RC inpatient 10.84 5.42 BCBS Louisiana PPO 5.42 percent of total billed charges 5.42 9.21 50% of Eligible Charges TAPE DURAPORE SILK 3 270 RC outpatient 10.84 8.67 BCBS Louisiana PPO 8.67 percent of total billed charges 5.96 9.21 80% of billed charge TAPE DURAPORE SILK 3 270 RC outpatient 10.84 8.67 Cigna Commercial PPO 5.96 percent of total billed charges 5.96 9.21 55% of Billed Charges TAPE DURAPORE SILK 3 270 RC inpatient 10.84 5.42 IMA of Louisiana Commercial PPO 9.21 percent of total billed charges 5.42 9.21 Inpatient Reimbursement at 85% of Billed Charges TAPE DURAPORE SILK 3 270 RC outpatient 10.84 8.67 IMA of Louisiana Commercial PPO 9.21 percent of total billed charges 5.96 9.21 Reimbursement at 85% of billed charges TAPE DURAPORE SILK 3 270 RC outpatient 10.84 8.67 Aetna Commercial PPO 5.96 percent of total billed charges 5.96 9.21 55 of billed Charges TAPE MICROFOAM 3 270 RC inpatient 79.92 39.96 BCBS Louisiana PPO 39.96 percent of total billed charges 39.96 67.93 50% of Eligible Charges TAPE MICROFOAM 3 270 RC outpatient 79.92 63.94 BCBS Louisiana PPO 63.94 percent of total billed charges 43.96 67.93 80% of billed charge TAPE MICROFOAM 3 270 RC outpatient 79.92 63.94 Cigna Commercial PPO 43.96 percent of total billed charges 43.96 67.93 55% of Billed Charges TAPE MICROFOAM 3 270 RC inpatient 79.92 39.96 IMA of Louisiana Commercial PPO 67.93 percent of total billed charges 39.96 67.93 Inpatient Reimbursement at 85% of Billed Charges TAPE MICROFOAM 3 270 RC outpatient 79.92 63.94 IMA of Louisiana Commercial PPO 67.93 percent of total billed charges 43.96 67.93 Reimbursement at 85% of billed charges TAPE MICROFOAM 3 270 RC outpatient 79.92 63.94 Aetna Commercial PPO 43.96 percent of total billed charges 43.96 67.93 55 of billed Charges TAPE TRANSPORE CLEAR 3 270 RC inpatient 12.04 6.02 BCBS Louisiana PPO 6.02 percent of total billed charges 6.02 10.23 50% of Eligible Charges TAPE TRANSPORE CLEAR 3 270 RC outpatient 12.04 9.63 BCBS Louisiana PPO 9.63 percent of total billed charges 6.62 10.23 80% of billed charge TAPE TRANSPORE CLEAR 3 270 RC outpatient 12.04 9.63 Cigna Commercial PPO 6.62 percent of total billed charges 6.62 10.23 55% of Billed Charges TAPE TRANSPORE CLEAR 3 270 RC inpatient 12.04 6.02 IMA of Louisiana Commercial PPO 10.23 percent of total billed charges 6.02 10.23 Inpatient Reimbursement at 85% of Billed Charges TAPE TRANSPORE CLEAR 3 270 RC outpatient 12.04 9.63 IMA of Louisiana Commercial PPO 10.23 percent of total billed charges 6.62 10.23 Reimbursement at 85% of billed charges TAPE TRANSPORE CLEAR 3 270 RC outpatient 12.04 9.63 Aetna Commercial PPO 6.62 percent of total billed charges 6.62 10.23 55 of billed Charges URINAL W/TRANSPARENT LID 270 RC inpatient 166.25 83.13 BCBS Louisiana PPO 83.13 percent of total billed charges 83.13 141.31 50% of Eligible Charges URINAL W/TRANSPARENT LID 270 RC outpatient 166.25 133 BCBS Louisiana PPO 133 percent of total billed charges 91.44 141.31 80% of billed charge URINAL W/TRANSPARENT LID 270 RC outpatient 166.25 133 Cigna Commercial PPO 91.44 percent of total billed charges 91.44 141.31 55% of Billed Charges URINAL W/TRANSPARENT LID 270 RC inpatient 166.25 83.13 IMA of Louisiana Commercial PPO 141.31 percent of total billed charges 83.13 141.31 Inpatient Reimbursement at 85% of Billed Charges URINAL W/TRANSPARENT LID 270 RC outpatient 166.25 133 IMA of Louisiana Commercial PPO 141.31 percent of total billed charges 91.44 141.31 Reimbursement at 85% of billed charges URINAL W/TRANSPARENT LID 270 RC outpatient 166.25 133 Aetna Commercial PPO 91.44 percent of total billed charges 91.44 141.31 55 of billed Charges ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC inpatient 2261.54 1130.77 BCBS Louisiana PPO 1130.77 percent of total billed charges 1130.77 1922.31 50% of Eligible Charges ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC outpatient 2261.54 1809.23 BCBS Louisiana PPO 1809.23 percent of total billed charges 836.77 1922.31 80% of billed charge ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC outpatient 2261.54 1809.23 Cigna Commercial PPO 1311.69 percent of total billed charges 836.77 1922.31 58% of Billed Charges/$500 Threshold ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC inpatient 2261.54 1130.77 IMA of Louisiana Commercial PPO 1922.31 percent of total billed charges 1130.77 1922.31 Inpatient Reimbursement at 85% of Billed Charges ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC outpatient 2261.54 1809.23 IMA of Louisiana Commercial PPO 1922.31 percent of total billed charges 836.77 1922.31 Reimbursement at 85% of billed charges ANTERIOR TIBIALIS TENDON C1713 HCPCS 278 RC outpatient 2261.54 1809.23 Aetna Commercial PPO 836.77 percent of total billed charges 836.77 1922.31 37% Of Billed Charges 2000 PLASTER ROLL 4 X 5 YDS 272 RC inpatient 5.47 2.74 BCBS Louisiana PPO 2.74 percent of total billed charges 2.74 4.65 50% of Eligible Charges PLASTER ROLL 4 X 5 YDS 272 RC outpatient 5.47 4.38 BCBS Louisiana PPO 4.38 percent of total billed charges 3.01 4.65 80% of billed charge PLASTER ROLL 4 X 5 YDS 272 RC outpatient 5.47 4.38 Cigna Commercial PPO 3.01 percent of total billed charges 3.01 4.65 55% of Billed Charges PLASTER ROLL 4 X 5 YDS 272 RC inpatient 5.47 2.74 IMA of Louisiana Commercial PPO 4.65 percent of total billed charges 2.74 4.65 Inpatient Reimbursement at 85% of Billed Charges PLASTER ROLL 4 X 5 YDS 272 RC outpatient 5.47 4.38 IMA of Louisiana Commercial PPO 4.65 percent of total billed charges 3.01 4.65 Reimbursement at 85% of billed charges PLASTER ROLL 4 X 5 YDS 272 RC outpatient 5.47 4.38 Aetna Commercial PPO 3.01 percent of total billed charges 3.01 4.65 55 of billed Charges MASK OXY MED CONC 7' TU 1040 270 RC inpatient 275.24 137.62 BCBS Louisiana PPO 137.62 percent of total billed charges 137.62 233.95 50% of Eligible Charges MASK OXY MED CONC 7' TU 1040 270 RC outpatient 275.24 220.19 BCBS Louisiana PPO 220.19 percent of total billed charges 151.38 233.95 80% of billed charge MASK OXY MED CONC 7' TU 1040 270 RC outpatient 275.24 220.19 Cigna Commercial PPO 151.38 percent of total billed charges 151.38 233.95 55% of Billed Charges MASK OXY MED CONC 7' TU 1040 270 RC inpatient 275.24 137.62 IMA of Louisiana Commercial PPO 233.95 percent of total billed charges 137.62 233.95 Inpatient Reimbursement at 85% of Billed Charges MASK OXY MED CONC 7' TU 1040 270 RC outpatient 275.24 220.19 IMA of Louisiana Commercial PPO 233.95 percent of total billed charges 151.38 233.95 Reimbursement at 85% of billed charges MASK OXY MED CONC 7' TU 1040 270 RC outpatient 275.24 220.19 Aetna Commercial PPO 151.38 percent of total billed charges 151.38 233.95 55 of billed Charges SYRINGE 1CC 27G X .5 272 RC inpatient 34.28 17.14 BCBS Louisiana PPO 17.14 percent of total billed charges 17.14 29.14 50% of Eligible Charges SYRINGE 1CC 27G X .5 272 RC outpatient 34.28 27.42 BCBS Louisiana PPO 27.42 percent of total billed charges 18.85 29.14 80% of billed charge SYRINGE 1CC 27G X .5 272 RC outpatient 34.28 27.42 Cigna Commercial PPO 18.85 percent of total billed charges 18.85 29.14 55% of Billed Charges SYRINGE 1CC 27G X .5 272 RC inpatient 34.28 17.14 IMA of Louisiana Commercial PPO 29.14 percent of total billed charges 17.14 29.14 Inpatient Reimbursement at 85% of Billed Charges SYRINGE 1CC 27G X .5 272 RC outpatient 34.28 27.42 IMA of Louisiana Commercial PPO 29.14 percent of total billed charges 18.85 29.14 Reimbursement at 85% of billed charges SYRINGE 1CC 27G X .5 272 RC outpatient 34.28 27.42 Aetna Commercial PPO 18.85 percent of total billed charges 18.85 29.14 55 of billed Charges TAPE TRANSPARENT LF 1 270 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges TAPE TRANSPARENT LF 1 270 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge TAPE TRANSPARENT LF 1 270 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges TAPE TRANSPARENT LF 1 270 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges TAPE TRANSPARENT LF 1 270 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges TAPE TRANSPARENT LF 1 270 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges TAPE TRANSPORE TRANSPARENT 2 270 RC inpatient 29.56 14.78 BCBS Louisiana PPO 14.78 percent of total billed charges 14.78 25.13 50% of Eligible Charges TAPE TRANSPORE TRANSPARENT 2 270 RC outpatient 29.56 23.65 BCBS Louisiana PPO 23.65 percent of total billed charges 16.26 25.13 80% of billed charge TAPE TRANSPORE TRANSPARENT 2 270 RC outpatient 29.56 23.65 Cigna Commercial PPO 16.26 percent of total billed charges 16.26 25.13 55% of Billed Charges TAPE TRANSPORE TRANSPARENT 2 270 RC inpatient 29.56 14.78 IMA of Louisiana Commercial PPO 25.13 percent of total billed charges 14.78 25.13 Inpatient Reimbursement at 85% of Billed Charges TAPE TRANSPORE TRANSPARENT 2 270 RC outpatient 29.56 23.65 IMA of Louisiana Commercial PPO 25.13 percent of total billed charges 16.26 25.13 Reimbursement at 85% of billed charges TAPE TRANSPORE TRANSPARENT 2 270 RC outpatient 29.56 23.65 Aetna Commercial PPO 16.26 percent of total billed charges 16.26 25.13 55 of billed Charges IMMOBILIZER UNIVERSAL KNEE 20 270 RC inpatient 65.12 32.56 BCBS Louisiana PPO 32.56 percent of total billed charges 32.56 55.35 50% of Eligible Charges IMMOBILIZER UNIVERSAL KNEE 20 270 RC outpatient 65.12 52.1 BCBS Louisiana PPO 52.1 percent of total billed charges 35.82 55.35 80% of billed charge IMMOBILIZER UNIVERSAL KNEE 20 270 RC outpatient 65.12 52.1 Cigna Commercial PPO 35.82 percent of total billed charges 35.82 55.35 55% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 20 270 RC inpatient 65.12 32.56 IMA of Louisiana Commercial PPO 55.35 percent of total billed charges 32.56 55.35 Inpatient Reimbursement at 85% of Billed Charges IMMOBILIZER UNIVERSAL KNEE 20 270 RC outpatient 65.12 52.1 IMA of Louisiana Commercial PPO 55.35 percent of total billed charges 35.82 55.35 Reimbursement at 85% of billed charges IMMOBILIZER UNIVERSAL KNEE 20 270 RC outpatient 65.12 52.1 Aetna Commercial PPO 35.82 percent of total billed charges 35.82 55.35 55 of billed Charges CATHETER 14FR LATEX FREE 272 RC inpatient 228.76 114.38 BCBS Louisiana PPO 114.38 percent of total billed charges 114.38 194.45 50% of Eligible Charges CATHETER 14FR LATEX FREE 272 RC outpatient 228.76 183.01 BCBS Louisiana PPO 183.01 percent of total billed charges 125.82 194.45 80% of billed charge CATHETER 14FR LATEX FREE 272 RC outpatient 228.76 183.01 Cigna Commercial PPO 125.82 percent of total billed charges 125.82 194.45 55% of Billed Charges CATHETER 14FR LATEX FREE 272 RC inpatient 228.76 114.38 IMA of Louisiana Commercial PPO 194.45 percent of total billed charges 114.38 194.45 Inpatient Reimbursement at 85% of Billed Charges CATHETER 14FR LATEX FREE 272 RC outpatient 228.76 183.01 IMA of Louisiana Commercial PPO 194.45 percent of total billed charges 125.82 194.45 Reimbursement at 85% of billed charges CATHETER 14FR LATEX FREE 272 RC outpatient 228.76 183.01 Aetna Commercial PPO 125.82 percent of total billed charges 125.82 194.45 55 of billed Charges SUTURE 3-0 VICRYL X-1 J458H 272 RC inpatient 9 4.5 BCBS Louisiana PPO 4.5 percent of total billed charges 4.5 7.65 50% of Eligible Charges SUTURE 3-0 VICRYL X-1 J458H 272 RC outpatient 9 7.2 BCBS Louisiana PPO 7.2 percent of total billed charges 4.95 7.65 80% of billed charge SUTURE 3-0 VICRYL X-1 J458H 272 RC outpatient 9 7.2 Cigna Commercial PPO 4.95 percent of total billed charges 4.95 7.65 55% of Billed Charges SUTURE 3-0 VICRYL X-1 J458H 272 RC inpatient 9 4.5 IMA of Louisiana Commercial PPO 7.65 percent of total billed charges 4.5 7.65 Inpatient Reimbursement at 85% of Billed Charges SUTURE 3-0 VICRYL X-1 J458H 272 RC outpatient 9 7.2 IMA of Louisiana Commercial PPO 7.65 percent of total billed charges 4.95 7.65 Reimbursement at 85% of billed charges SUTURE 3-0 VICRYL X-1 J458H 272 RC outpatient 9 7.2 Aetna Commercial PPO 4.95 percent of total billed charges 4.95 7.65 55 of billed Charges INSTR. POUCH STERILE 272 RC inpatient 15.06 7.53 BCBS Louisiana PPO 7.53 percent of total billed charges 7.53 12.8 50% of Eligible Charges INSTR. POUCH STERILE 272 RC outpatient 15.06 12.05 BCBS Louisiana PPO 12.05 percent of total billed charges 8.28 12.8 80% of billed charge INSTR. POUCH STERILE 272 RC outpatient 15.06 12.05 Cigna Commercial PPO 8.28 percent of total billed charges 8.28 12.8 55% of Billed Charges INSTR. POUCH STERILE 272 RC inpatient 15.06 7.53 IMA of Louisiana Commercial PPO 12.8 percent of total billed charges 7.53 12.8 Inpatient Reimbursement at 85% of Billed Charges INSTR. POUCH STERILE 272 RC outpatient 15.06 12.05 IMA of Louisiana Commercial PPO 12.8 percent of total billed charges 8.28 12.8 Reimbursement at 85% of billed charges INSTR. POUCH STERILE 272 RC outpatient 15.06 12.05 Aetna Commercial PPO 8.28 percent of total billed charges 8.28 12.8 55 of billed Charges GLOVE LATEX FREE SZ 7 272 RC inpatient 6.72 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 3.36 5.71 50% of Eligible Charges GLOVE LATEX FREE SZ 7 272 RC outpatient 6.72 5.38 BCBS Louisiana PPO 5.38 percent of total billed charges 3.7 5.71 80% of billed charge GLOVE LATEX FREE SZ 7 272 RC outpatient 6.72 5.38 Cigna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55% of Billed Charges GLOVE LATEX FREE SZ 7 272 RC inpatient 6.72 3.36 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.36 5.71 Inpatient Reimbursement at 85% of Billed Charges GLOVE LATEX FREE SZ 7 272 RC outpatient 6.72 5.38 IMA of Louisiana Commercial PPO 5.71 percent of total billed charges 3.7 5.71 Reimbursement at 85% of billed charges GLOVE LATEX FREE SZ 7 272 RC outpatient 6.72 5.38 Aetna Commercial PPO 3.7 percent of total billed charges 3.7 5.71 55 of billed Charges PREP CHLORAPREP 26 ML 272 RC inpatient 32.94 16.47 BCBS Louisiana PPO 16.47 percent of total billed charges 16.47 28 50% of Eligible Charges PREP CHLORAPREP 26 ML 272 RC outpatient 32.94 26.35 BCBS Louisiana PPO 26.35 percent of total billed charges 18.12 28 80% of billed charge PREP CHLORAPREP 26 ML 272 RC outpatient 32.94 26.35 Cigna Commercial PPO 18.12 percent of total billed charges 18.12 28 55% of Billed Charges PREP CHLORAPREP 26 ML 272 RC inpatient 32.94 16.47 IMA of Louisiana Commercial PPO 28 percent of total billed charges 16.47 28 Inpatient Reimbursement at 85% of Billed Charges PREP CHLORAPREP 26 ML 272 RC outpatient 32.94 26.35 IMA of Louisiana Commercial PPO 28 percent of total billed charges 18.12 28 Reimbursement at 85% of billed charges PREP CHLORAPREP 26 ML 272 RC outpatient 32.94 26.35 Aetna Commercial PPO 18.12 percent of total billed charges 18.12 28 55 of billed Charges DRAPE KC ORTHO ARTS U-DRAPE 272 RC inpatient 62.77 31.39 BCBS Louisiana PPO 31.39 percent of total billed charges 31.39 53.35 50% of Eligible Charges DRAPE KC ORTHO ARTS U-DRAPE 272 RC outpatient 62.77 50.22 BCBS Louisiana PPO 50.22 percent of total billed charges 34.52 53.35 80% of billed charge DRAPE KC ORTHO ARTS U-DRAPE 272 RC outpatient 62.77 50.22 Cigna Commercial PPO 34.52 percent of total billed charges 34.52 53.35 55% of Billed Charges DRAPE KC ORTHO ARTS U-DRAPE 272 RC inpatient 62.77 31.39 IMA of Louisiana Commercial PPO 53.35 percent of total billed charges 31.39 53.35 Inpatient Reimbursement at 85% of Billed Charges DRAPE KC ORTHO ARTS U-DRAPE 272 RC outpatient 62.77 50.22 IMA of Louisiana Commercial PPO 53.35 percent of total billed charges 34.52 53.35 Reimbursement at 85% of billed charges DRAPE KC ORTHO ARTS U-DRAPE 272 RC outpatient 62.77 50.22 Aetna Commercial PPO 34.52 percent of total billed charges 34.52 53.35 55 of billed Charges PAD STAYFREE MAXITHIN #4 272 RC inpatient 338.56 169.28 BCBS Louisiana PPO 169.28 percent of total billed charges 169.28 287.78 50% of Eligible Charges PAD STAYFREE MAXITHIN #4 272 RC outpatient 338.56 270.85 BCBS Louisiana PPO 270.85 percent of total billed charges 186.21 287.78 80% of billed charge PAD STAYFREE MAXITHIN #4 272 RC outpatient 338.56 270.85 Cigna Commercial PPO 186.21 percent of total billed charges 186.21 287.78 55% of Billed Charges PAD STAYFREE MAXITHIN #4 272 RC inpatient 338.56 169.28 IMA of Louisiana Commercial PPO 287.78 percent of total billed charges 169.28 287.78 Inpatient Reimbursement at 85% of Billed Charges PAD STAYFREE MAXITHIN #4 272 RC outpatient 338.56 270.85 IMA of Louisiana Commercial PPO 287.78 percent of total billed charges 186.21 287.78 Reimbursement at 85% of billed charges PAD STAYFREE MAXITHIN #4 272 RC outpatient 338.56 270.85 Aetna Commercial PPO 186.21 percent of total billed charges 186.21 287.78 55 of billed Charges LMA SOFTSEAL SIZE 2.5 272 RC inpatient 267.68 133.84 BCBS Louisiana PPO 133.84 percent of total billed charges 133.84 227.53 50% of Eligible Charges LMA SOFTSEAL SIZE 2.5 272 RC outpatient 267.68 214.14 BCBS Louisiana PPO 214.14 percent of total billed charges 147.22 227.53 80% of billed charge LMA SOFTSEAL SIZE 2.5 272 RC outpatient 267.68 214.14 Cigna Commercial PPO 147.22 percent of total billed charges 147.22 227.53 55% of Billed Charges LMA SOFTSEAL SIZE 2.5 272 RC inpatient 267.68 133.84 IMA of Louisiana Commercial PPO 227.53 percent of total billed charges 133.84 227.53 Inpatient Reimbursement at 85% of Billed Charges LMA SOFTSEAL SIZE 2.5 272 RC outpatient 267.68 214.14 IMA of Louisiana Commercial PPO 227.53 percent of total billed charges 147.22 227.53 Reimbursement at 85% of billed charges LMA SOFTSEAL SIZE 2.5 272 RC outpatient 267.68 214.14 Aetna Commercial PPO 147.22 percent of total billed charges 147.22 227.53 55 of billed Charges SAW BLADE 2108-352 272 RC inpatient 91.28 45.64 BCBS Louisiana PPO 45.64 percent of total billed charges 45.64 77.59 50% of Eligible Charges SAW BLADE 2108-352 272 RC outpatient 91.28 73.02 BCBS Louisiana PPO 73.02 percent of total billed charges 50.2 77.59 80% of billed charge SAW BLADE 2108-352 272 RC outpatient 91.28 73.02 Cigna Commercial PPO 50.2 percent of total billed charges 50.2 77.59 55% of Billed Charges SAW BLADE 2108-352 272 RC inpatient 91.28 45.64 IMA of Louisiana Commercial PPO 77.59 percent of total billed charges 45.64 77.59 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-352 272 RC outpatient 91.28 73.02 IMA of Louisiana Commercial PPO 77.59 percent of total billed charges 50.2 77.59 Reimbursement at 85% of billed charges SAW BLADE 2108-352 272 RC outpatient 91.28 73.02 Aetna Commercial PPO 50.2 percent of total billed charges 50.2 77.59 55 of billed Charges SECONDARY TUBING IV ADMIN SET 272 RC inpatient 5.24 2.62 BCBS Louisiana PPO 2.62 percent of total billed charges 2.62 4.45 50% of Eligible Charges SECONDARY TUBING IV ADMIN SET 272 RC outpatient 5.24 4.19 BCBS Louisiana PPO 4.19 percent of total billed charges 2.88 4.45 80% of billed charge SECONDARY TUBING IV ADMIN SET 272 RC outpatient 5.24 4.19 Cigna Commercial PPO 2.88 percent of total billed charges 2.88 4.45 55% of Billed Charges SECONDARY TUBING IV ADMIN SET 272 RC inpatient 5.24 2.62 IMA of Louisiana Commercial PPO 4.45 percent of total billed charges 2.62 4.45 Inpatient Reimbursement at 85% of Billed Charges SECONDARY TUBING IV ADMIN SET 272 RC outpatient 5.24 4.19 IMA of Louisiana Commercial PPO 4.45 percent of total billed charges 2.88 4.45 Reimbursement at 85% of billed charges SECONDARY TUBING IV ADMIN SET 272 RC outpatient 5.24 4.19 Aetna Commercial PPO 2.88 percent of total billed charges 2.88 4.45 55 of billed Charges KAM-VAC SUCTION SUPER SUCKER 272 RC inpatient 2500 1250 BCBS Louisiana PPO 1250 percent of total billed charges 1250 2125 50% of Eligible Charges KAM-VAC SUCTION SUPER SUCKER 272 RC outpatient 2500 2000 BCBS Louisiana PPO 2000 percent of total billed charges 1375 2125 80% of billed charge KAM-VAC SUCTION SUPER SUCKER 272 RC outpatient 2500 2000 Cigna Commercial PPO 1375 percent of total billed charges 1375 2125 55% of Billed Charges KAM-VAC SUCTION SUPER SUCKER 272 RC inpatient 2500 1250 IMA of Louisiana Commercial PPO 2125 percent of total billed charges 1250 2125 Inpatient Reimbursement at 85% of Billed Charges KAM-VAC SUCTION SUPER SUCKER 272 RC outpatient 2500 2000 IMA of Louisiana Commercial PPO 2125 percent of total billed charges 1375 2125 Reimbursement at 85% of billed charges KAM-VAC SUCTION SUPER SUCKER 272 RC outpatient 2500 2000 Aetna Commercial PPO 1375 percent of total billed charges 1375 2125 55 of billed Charges SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 24MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC inpatient 13.88 6.94 BCBS Louisiana PPO 6.94 percent of total billed charges 6.94 11.8 50% of Eligible Charges DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC outpatient 13.88 11.1 BCBS Louisiana PPO 11.1 percent of total billed charges 7.63 11.8 80% of billed charge DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC outpatient 13.88 11.1 Cigna Commercial PPO 7.63 percent of total billed charges 7.63 11.8 55% of Billed Charges DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC inpatient 13.88 6.94 IMA of Louisiana Commercial PPO 11.8 percent of total billed charges 6.94 11.8 Inpatient Reimbursement at 85% of Billed Charges DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC outpatient 13.88 11.1 IMA of Louisiana Commercial PPO 11.8 percent of total billed charges 7.63 11.8 Reimbursement at 85% of billed charges DRAPE IOBAN LARGE - WITHOUT IODINE 272 RC outpatient 13.88 11.1 Aetna Commercial PPO 7.63 percent of total billed charges 7.63 11.8 55 of billed Charges SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW 4.0MM CANC. 40MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 SENSATRAC WHITEFOAM SMALL - KCI 272 RC inpatient 505.22 252.61 BCBS Louisiana PPO 252.61 percent of total billed charges 252.61 429.44 50% of Eligible Charges SENSATRAC WHITEFOAM SMALL - KCI 272 RC outpatient 505.22 404.18 BCBS Louisiana PPO 404.18 percent of total billed charges 277.87 429.44 80% of billed charge SENSATRAC WHITEFOAM SMALL - KCI 272 RC outpatient 505.22 404.18 Cigna Commercial PPO 277.87 percent of total billed charges 277.87 429.44 55% of Billed Charges SENSATRAC WHITEFOAM SMALL - KCI 272 RC inpatient 505.22 252.61 IMA of Louisiana Commercial PPO 429.44 percent of total billed charges 252.61 429.44 Inpatient Reimbursement at 85% of Billed Charges SENSATRAC WHITEFOAM SMALL - KCI 272 RC outpatient 505.22 404.18 IMA of Louisiana Commercial PPO 429.44 percent of total billed charges 277.87 429.44 Reimbursement at 85% of billed charges SENSATRAC WHITEFOAM SMALL - KCI 272 RC outpatient 505.22 404.18 Aetna Commercial PPO 277.87 percent of total billed charges 277.87 429.44 55 of billed Charges SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 22.2 51 80% of billed charge SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Cigna Commercial PPO 34.8 percent of total billed charges 22.2 51 58% of Billed Charges/$500 Threshold SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 22.2 51 Reimbursement at 85% of billed charges SCREW CORTEX 4.5 X 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 60 48 Aetna Commercial PPO 22.2 percent of total billed charges 22.2 51 37% Of Billed Charges 2000 JACKSON TABLE DRAPE 270 RC inpatient 478.13 239.07 BCBS Louisiana PPO 239.07 percent of total billed charges 239.07 406.41 50% of Eligible Charges JACKSON TABLE DRAPE 270 RC outpatient 478.13 382.5 BCBS Louisiana PPO 382.5 percent of total billed charges 262.97 406.41 80% of billed charge JACKSON TABLE DRAPE 270 RC outpatient 478.13 382.5 Cigna Commercial PPO 262.97 percent of total billed charges 262.97 406.41 55% of Billed Charges JACKSON TABLE DRAPE 270 RC inpatient 478.13 239.07 IMA of Louisiana Commercial PPO 406.41 percent of total billed charges 239.07 406.41 Inpatient Reimbursement at 85% of Billed Charges JACKSON TABLE DRAPE 270 RC outpatient 478.13 382.5 IMA of Louisiana Commercial PPO 406.41 percent of total billed charges 262.97 406.41 Reimbursement at 85% of billed charges JACKSON TABLE DRAPE 270 RC outpatient 478.13 382.5 Aetna Commercial PPO 262.97 percent of total billed charges 262.97 406.41 55 of billed Charges GLOVE SENSICARE 8 272 RC inpatient 17.18 8.59 BCBS Louisiana PPO 8.59 percent of total billed charges 8.59 14.6 50% of Eligible Charges GLOVE SENSICARE 8 272 RC outpatient 17.18 13.74 BCBS Louisiana PPO 13.74 percent of total billed charges 9.45 14.6 80% of billed charge GLOVE SENSICARE 8 272 RC outpatient 17.18 13.74 Cigna Commercial PPO 9.45 percent of total billed charges 9.45 14.6 55% of Billed Charges GLOVE SENSICARE 8 272 RC inpatient 17.18 8.59 IMA of Louisiana Commercial PPO 14.6 percent of total billed charges 8.59 14.6 Inpatient Reimbursement at 85% of Billed Charges GLOVE SENSICARE 8 272 RC outpatient 17.18 13.74 IMA of Louisiana Commercial PPO 14.6 percent of total billed charges 9.45 14.6 Reimbursement at 85% of billed charges GLOVE SENSICARE 8 272 RC outpatient 17.18 13.74 Aetna Commercial PPO 9.45 percent of total billed charges 9.45 14.6 55 of billed Charges BELT GAIT UNIVERSAL 270 RC inpatient 30.72 15.36 BCBS Louisiana PPO 15.36 percent of total billed charges 15.36 26.11 50% of Eligible Charges BELT GAIT UNIVERSAL 270 RC outpatient 30.72 24.58 BCBS Louisiana PPO 24.58 percent of total billed charges 16.9 26.11 80% of billed charge BELT GAIT UNIVERSAL 270 RC outpatient 30.72 24.58 Cigna Commercial PPO 16.9 percent of total billed charges 16.9 26.11 55% of Billed Charges BELT GAIT UNIVERSAL 270 RC inpatient 30.72 15.36 IMA of Louisiana Commercial PPO 26.11 percent of total billed charges 15.36 26.11 Inpatient Reimbursement at 85% of Billed Charges BELT GAIT UNIVERSAL 270 RC outpatient 30.72 24.58 IMA of Louisiana Commercial PPO 26.11 percent of total billed charges 16.9 26.11 Reimbursement at 85% of billed charges BELT GAIT UNIVERSAL 270 RC outpatient 30.72 24.58 Aetna Commercial PPO 16.9 percent of total billed charges 16.9 26.11 55 of billed Charges SUTURE 5-0 PROLENE C-1 8720H 272 RC inpatient 62.4 31.2 BCBS Louisiana PPO 31.2 percent of total billed charges 31.2 53.04 50% of Eligible Charges SUTURE 5-0 PROLENE C-1 8720H 272 RC outpatient 62.4 49.92 BCBS Louisiana PPO 49.92 percent of total billed charges 34.32 53.04 80% of billed charge SUTURE 5-0 PROLENE C-1 8720H 272 RC outpatient 62.4 49.92 Cigna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55% of Billed Charges SUTURE 5-0 PROLENE C-1 8720H 272 RC inpatient 62.4 31.2 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 31.2 53.04 Inpatient Reimbursement at 85% of Billed Charges SUTURE 5-0 PROLENE C-1 8720H 272 RC outpatient 62.4 49.92 IMA of Louisiana Commercial PPO 53.04 percent of total billed charges 34.32 53.04 Reimbursement at 85% of billed charges SUTURE 5-0 PROLENE C-1 8720H 272 RC outpatient 62.4 49.92 Aetna Commercial PPO 34.32 percent of total billed charges 34.32 53.04 55 of billed Charges CLIP LIGATN APPLIER LG 272 RC inpatient 245.84 122.92 BCBS Louisiana PPO 122.92 percent of total billed charges 122.92 208.96 50% of Eligible Charges CLIP LIGATN APPLIER LG 272 RC outpatient 245.84 196.67 BCBS Louisiana PPO 196.67 percent of total billed charges 135.21 208.96 80% of billed charge CLIP LIGATN APPLIER LG 272 RC outpatient 245.84 196.67 Cigna Commercial PPO 135.21 percent of total billed charges 135.21 208.96 55% of Billed Charges CLIP LIGATN APPLIER LG 272 RC inpatient 245.84 122.92 IMA of Louisiana Commercial PPO 208.96 percent of total billed charges 122.92 208.96 Inpatient Reimbursement at 85% of Billed Charges CLIP LIGATN APPLIER LG 272 RC outpatient 245.84 196.67 IMA of Louisiana Commercial PPO 208.96 percent of total billed charges 135.21 208.96 Reimbursement at 85% of billed charges CLIP LIGATN APPLIER LG 272 RC outpatient 245.84 196.67 Aetna Commercial PPO 135.21 percent of total billed charges 135.21 208.96 55 of billed Charges WALKER WITH WHEELS 5 270 RC inpatient 93.08 46.54 BCBS Louisiana PPO 46.54 percent of total billed charges 46.54 79.12 50% of Eligible Charges WALKER WITH WHEELS 5 270 RC outpatient 93.08 74.46 BCBS Louisiana PPO 74.46 percent of total billed charges 51.19 79.12 80% of billed charge WALKER WITH WHEELS 5 270 RC outpatient 93.08 74.46 Cigna Commercial PPO 51.19 percent of total billed charges 51.19 79.12 55% of Billed Charges WALKER WITH WHEELS 5 270 RC inpatient 93.08 46.54 IMA of Louisiana Commercial PPO 79.12 percent of total billed charges 46.54 79.12 Inpatient Reimbursement at 85% of Billed Charges WALKER WITH WHEELS 5 270 RC outpatient 93.08 74.46 IMA of Louisiana Commercial PPO 79.12 percent of total billed charges 51.19 79.12 Reimbursement at 85% of billed charges WALKER WITH WHEELS 5 270 RC outpatient 93.08 74.46 Aetna Commercial PPO 51.19 percent of total billed charges 51.19 79.12 55 of billed Charges SUTURE 0 SILK TIE 30 A306H 272 RC inpatient 6.04 3.02 BCBS Louisiana PPO 3.02 percent of total billed charges 3.02 5.13 50% of Eligible Charges SUTURE 0 SILK TIE 30 A306H 272 RC outpatient 6.04 4.83 BCBS Louisiana PPO 4.83 percent of total billed charges 3.32 5.13 80% of billed charge SUTURE 0 SILK TIE 30 A306H 272 RC outpatient 6.04 4.83 Cigna Commercial PPO 3.32 percent of total billed charges 3.32 5.13 55% of Billed Charges SUTURE 0 SILK TIE 30 A306H 272 RC inpatient 6.04 3.02 IMA of Louisiana Commercial PPO 5.13 percent of total billed charges 3.02 5.13 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 SILK TIE 30 A306H 272 RC outpatient 6.04 4.83 IMA of Louisiana Commercial PPO 5.13 percent of total billed charges 3.32 5.13 Reimbursement at 85% of billed charges SUTURE 0 SILK TIE 30 A306H 272 RC outpatient 6.04 4.83 Aetna Commercial PPO 3.32 percent of total billed charges 3.32 5.13 55 of billed Charges STIMUPLEX NEEDLE 4 272 RC inpatient 50.21 25.11 BCBS Louisiana PPO 25.11 percent of total billed charges 25.11 42.68 50% of Eligible Charges STIMUPLEX NEEDLE 4 272 RC outpatient 50.21 40.17 BCBS Louisiana PPO 40.17 percent of total billed charges 27.62 42.68 80% of billed charge STIMUPLEX NEEDLE 4 272 RC outpatient 50.21 40.17 Cigna Commercial PPO 27.62 percent of total billed charges 27.62 42.68 55% of Billed Charges STIMUPLEX NEEDLE 4 272 RC inpatient 50.21 25.11 IMA of Louisiana Commercial PPO 42.68 percent of total billed charges 25.11 42.68 Inpatient Reimbursement at 85% of Billed Charges STIMUPLEX NEEDLE 4 272 RC outpatient 50.21 40.17 IMA of Louisiana Commercial PPO 42.68 percent of total billed charges 27.62 42.68 Reimbursement at 85% of billed charges STIMUPLEX NEEDLE 4 272 RC outpatient 50.21 40.17 Aetna Commercial PPO 27.62 percent of total billed charges 27.62 42.68 55 of billed Charges STYLET ENDOTRACH STR SIP ADULT 270 RC inpatient 14.24 7.12 BCBS Louisiana PPO 7.12 percent of total billed charges 7.12 12.1 50% of Eligible Charges STYLET ENDOTRACH STR SIP ADULT 270 RC outpatient 14.24 11.39 BCBS Louisiana PPO 11.39 percent of total billed charges 7.83 12.1 80% of billed charge STYLET ENDOTRACH STR SIP ADULT 270 RC outpatient 14.24 11.39 Cigna Commercial PPO 7.83 percent of total billed charges 7.83 12.1 55% of Billed Charges STYLET ENDOTRACH STR SIP ADULT 270 RC inpatient 14.24 7.12 IMA of Louisiana Commercial PPO 12.1 percent of total billed charges 7.12 12.1 Inpatient Reimbursement at 85% of Billed Charges STYLET ENDOTRACH STR SIP ADULT 270 RC outpatient 14.24 11.39 IMA of Louisiana Commercial PPO 12.1 percent of total billed charges 7.83 12.1 Reimbursement at 85% of billed charges STYLET ENDOTRACH STR SIP ADULT 270 RC outpatient 14.24 11.39 Aetna Commercial PPO 7.83 percent of total billed charges 7.83 12.1 55 of billed Charges STAPLER SKIN 35 VISTA DISP WIDE 272 RC inpatient 98.56 49.28 BCBS Louisiana PPO 49.28 percent of total billed charges 49.28 83.78 50% of Eligible Charges STAPLER SKIN 35 VISTA DISP WIDE 272 RC outpatient 98.56 78.85 BCBS Louisiana PPO 78.85 percent of total billed charges 54.21 83.78 80% of billed charge STAPLER SKIN 35 VISTA DISP WIDE 272 RC outpatient 98.56 78.85 Cigna Commercial PPO 54.21 percent of total billed charges 54.21 83.78 55% of Billed Charges STAPLER SKIN 35 VISTA DISP WIDE 272 RC inpatient 98.56 49.28 IMA of Louisiana Commercial PPO 83.78 percent of total billed charges 49.28 83.78 Inpatient Reimbursement at 85% of Billed Charges STAPLER SKIN 35 VISTA DISP WIDE 272 RC outpatient 98.56 78.85 IMA of Louisiana Commercial PPO 83.78 percent of total billed charges 54.21 83.78 Reimbursement at 85% of billed charges STAPLER SKIN 35 VISTA DISP WIDE 272 RC outpatient 98.56 78.85 Aetna Commercial PPO 54.21 percent of total billed charges 54.21 83.78 55 of billed Charges DRILL BIT 2.0MM TWIST - MICRO 272 RC inpatient 103.92 51.96 BCBS Louisiana PPO 51.96 percent of total billed charges 51.96 88.33 50% of Eligible Charges DRILL BIT 2.0MM TWIST - MICRO 272 RC outpatient 103.92 83.14 BCBS Louisiana PPO 83.14 percent of total billed charges 57.16 88.33 80% of billed charge DRILL BIT 2.0MM TWIST - MICRO 272 RC outpatient 103.92 83.14 Cigna Commercial PPO 57.16 percent of total billed charges 57.16 88.33 55% of Billed Charges DRILL BIT 2.0MM TWIST - MICRO 272 RC inpatient 103.92 51.96 IMA of Louisiana Commercial PPO 88.33 percent of total billed charges 51.96 88.33 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.0MM TWIST - MICRO 272 RC outpatient 103.92 83.14 IMA of Louisiana Commercial PPO 88.33 percent of total billed charges 57.16 88.33 Reimbursement at 85% of billed charges DRILL BIT 2.0MM TWIST - MICRO 272 RC outpatient 103.92 83.14 Aetna Commercial PPO 57.16 percent of total billed charges 57.16 88.33 55 of billed Charges SALEM SUMP TUBE 14/16FR 272 RC inpatient 458.75 229.38 BCBS Louisiana PPO 229.38 percent of total billed charges 229.38 389.94 50% of Eligible Charges SALEM SUMP TUBE 14/16FR 272 RC outpatient 458.75 367 BCBS Louisiana PPO 367 percent of total billed charges 252.31 389.94 80% of billed charge SALEM SUMP TUBE 14/16FR 272 RC outpatient 458.75 367 Cigna Commercial PPO 252.31 percent of total billed charges 252.31 389.94 55% of Billed Charges SALEM SUMP TUBE 14/16FR 272 RC inpatient 458.75 229.38 IMA of Louisiana Commercial PPO 389.94 percent of total billed charges 229.38 389.94 Inpatient Reimbursement at 85% of Billed Charges SALEM SUMP TUBE 14/16FR 272 RC outpatient 458.75 367 IMA of Louisiana Commercial PPO 389.94 percent of total billed charges 252.31 389.94 Reimbursement at 85% of billed charges SALEM SUMP TUBE 14/16FR 272 RC outpatient 458.75 367 Aetna Commercial PPO 252.31 percent of total billed charges 252.31 389.94 55 of billed Charges PICC LINE DRESSING KIT 272 RC inpatient 475.54 237.77 BCBS Louisiana PPO 237.77 percent of total billed charges 237.77 404.21 50% of Eligible Charges PICC LINE DRESSING KIT 272 RC outpatient 475.54 380.43 BCBS Louisiana PPO 380.43 percent of total billed charges 261.55 404.21 80% of billed charge PICC LINE DRESSING KIT 272 RC outpatient 475.54 380.43 Cigna Commercial PPO 261.55 percent of total billed charges 261.55 404.21 55% of Billed Charges PICC LINE DRESSING KIT 272 RC inpatient 475.54 237.77 IMA of Louisiana Commercial PPO 404.21 percent of total billed charges 237.77 404.21 Inpatient Reimbursement at 85% of Billed Charges PICC LINE DRESSING KIT 272 RC outpatient 475.54 380.43 IMA of Louisiana Commercial PPO 404.21 percent of total billed charges 261.55 404.21 Reimbursement at 85% of billed charges PICC LINE DRESSING KIT 272 RC outpatient 475.54 380.43 Aetna Commercial PPO 261.55 percent of total billed charges 261.55 404.21 55 of billed Charges TOTAL HIP PACK 272 RC inpatient 669.38 334.69 BCBS Louisiana PPO 334.69 percent of total billed charges 334.69 568.97 50% of Eligible Charges TOTAL HIP PACK 272 RC outpatient 669.38 535.5 BCBS Louisiana PPO 535.5 percent of total billed charges 368.16 568.97 80% of billed charge TOTAL HIP PACK 272 RC outpatient 669.38 535.5 Cigna Commercial PPO 368.16 percent of total billed charges 368.16 568.97 55% of Billed Charges TOTAL HIP PACK 272 RC inpatient 669.38 334.69 IMA of Louisiana Commercial PPO 568.97 percent of total billed charges 334.69 568.97 Inpatient Reimbursement at 85% of Billed Charges TOTAL HIP PACK 272 RC outpatient 669.38 535.5 IMA of Louisiana Commercial PPO 568.97 percent of total billed charges 368.16 568.97 Reimbursement at 85% of billed charges TOTAL HIP PACK 272 RC outpatient 669.38 535.5 Aetna Commercial PPO 368.16 percent of total billed charges 368.16 568.97 55 of billed Charges TOURNIQUET 44 DISPOSABLE 272 RC inpatient 482.86 241.43 BCBS Louisiana PPO 241.43 percent of total billed charges 241.43 410.43 50% of Eligible Charges TOURNIQUET 44 DISPOSABLE 272 RC outpatient 482.86 386.29 BCBS Louisiana PPO 386.29 percent of total billed charges 265.57 410.43 80% of billed charge TOURNIQUET 44 DISPOSABLE 272 RC outpatient 482.86 386.29 Cigna Commercial PPO 265.57 percent of total billed charges 265.57 410.43 55% of Billed Charges TOURNIQUET 44 DISPOSABLE 272 RC inpatient 482.86 241.43 IMA of Louisiana Commercial PPO 410.43 percent of total billed charges 241.43 410.43 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 44 DISPOSABLE 272 RC outpatient 482.86 386.29 IMA of Louisiana Commercial PPO 410.43 percent of total billed charges 265.57 410.43 Reimbursement at 85% of billed charges TOURNIQUET 44 DISPOSABLE 272 RC outpatient 482.86 386.29 Aetna Commercial PPO 265.57 percent of total billed charges 265.57 410.43 55 of billed Charges PREP (CHLORAPREP) TINTED 10.5 ML 272 RC inpatient 13.16 6.58 BCBS Louisiana PPO 6.58 percent of total billed charges 6.58 11.19 50% of Eligible Charges PREP (CHLORAPREP) TINTED 10.5 ML 272 RC outpatient 13.16 10.53 BCBS Louisiana PPO 10.53 percent of total billed charges 7.24 11.19 80% of billed charge PREP (CHLORAPREP) TINTED 10.5 ML 272 RC outpatient 13.16 10.53 Cigna Commercial PPO 7.24 percent of total billed charges 7.24 11.19 55% of Billed Charges PREP (CHLORAPREP) TINTED 10.5 ML 272 RC inpatient 13.16 6.58 IMA of Louisiana Commercial PPO 11.19 percent of total billed charges 6.58 11.19 Inpatient Reimbursement at 85% of Billed Charges PREP (CHLORAPREP) TINTED 10.5 ML 272 RC outpatient 13.16 10.53 IMA of Louisiana Commercial PPO 11.19 percent of total billed charges 7.24 11.19 Reimbursement at 85% of billed charges PREP (CHLORAPREP) TINTED 10.5 ML 272 RC outpatient 13.16 10.53 Aetna Commercial PPO 7.24 percent of total billed charges 7.24 11.19 55 of billed Charges BI-POLAR CORD DISPOSABLE 272 RC inpatient 8.18 4.09 BCBS Louisiana PPO 4.09 percent of total billed charges 4.09 6.95 50% of Eligible Charges BI-POLAR CORD DISPOSABLE 272 RC outpatient 8.18 6.54 BCBS Louisiana PPO 6.54 percent of total billed charges 4.5 6.95 80% of billed charge BI-POLAR CORD DISPOSABLE 272 RC outpatient 8.18 6.54 Cigna Commercial PPO 4.5 percent of total billed charges 4.5 6.95 55% of Billed Charges BI-POLAR CORD DISPOSABLE 272 RC inpatient 8.18 4.09 IMA of Louisiana Commercial PPO 6.95 percent of total billed charges 4.09 6.95 Inpatient Reimbursement at 85% of Billed Charges BI-POLAR CORD DISPOSABLE 272 RC outpatient 8.18 6.54 IMA of Louisiana Commercial PPO 6.95 percent of total billed charges 4.5 6.95 Reimbursement at 85% of billed charges BI-POLAR CORD DISPOSABLE 272 RC outpatient 8.18 6.54 Aetna Commercial PPO 4.5 percent of total billed charges 4.5 6.95 55 of billed Charges SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC inpatient 470.95 235.48 BCBS Louisiana PPO 235.48 percent of total billed charges 235.48 400.31 50% of Eligible Charges SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC outpatient 470.95 376.76 BCBS Louisiana PPO 376.76 percent of total billed charges 174.25 400.31 80% of billed charge SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Cigna Commercial PPO 273.15 percent of total billed charges 174.25 400.31 58% of Billed Charges/$500 Threshold SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC inpatient 470.95 235.48 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 235.48 400.31 Inpatient Reimbursement at 85% of Billed Charges SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC outpatient 470.95 376.76 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 174.25 400.31 Reimbursement at 85% of billed charges SCREW 7.3MM TI CANN. 16MM/75MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Aetna Commercial PPO 174.25 percent of total billed charges 174.25 400.31 37% Of Billed Charges 2000 SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC inpatient 470.95 235.48 BCBS Louisiana PPO 235.48 percent of total billed charges 235.48 400.31 50% of Eligible Charges SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC outpatient 470.95 376.76 BCBS Louisiana PPO 376.76 percent of total billed charges 174.25 400.31 80% of billed charge SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Cigna Commercial PPO 273.15 percent of total billed charges 174.25 400.31 58% of Billed Charges/$500 Threshold SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC inpatient 470.95 235.48 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 235.48 400.31 Inpatient Reimbursement at 85% of Billed Charges SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC outpatient 470.95 376.76 IMA of Louisiana Commercial PPO 400.31 percent of total billed charges 174.25 400.31 Reimbursement at 85% of billed charges SCREW 7.3MM TI CANN. 16MM/90MM C1713 HCPCS 278 RC outpatient 470.95 376.76 Aetna Commercial PPO 174.25 percent of total billed charges 174.25 400.31 37% Of Billed Charges 2000 TOURNIQUET 12 DISPOSIBLE 272 RC inpatient 482.86 241.43 BCBS Louisiana PPO 241.43 percent of total billed charges 241.43 410.43 50% of Eligible Charges TOURNIQUET 12 DISPOSIBLE 272 RC outpatient 482.86 386.29 BCBS Louisiana PPO 386.29 percent of total billed charges 265.57 410.43 80% of billed charge TOURNIQUET 12 DISPOSIBLE 272 RC outpatient 482.86 386.29 Cigna Commercial PPO 265.57 percent of total billed charges 265.57 410.43 55% of Billed Charges TOURNIQUET 12 DISPOSIBLE 272 RC inpatient 482.86 241.43 IMA of Louisiana Commercial PPO 410.43 percent of total billed charges 241.43 410.43 Inpatient Reimbursement at 85% of Billed Charges TOURNIQUET 12 DISPOSIBLE 272 RC outpatient 482.86 386.29 IMA of Louisiana Commercial PPO 410.43 percent of total billed charges 265.57 410.43 Reimbursement at 85% of billed charges TOURNIQUET 12 DISPOSIBLE 272 RC outpatient 482.86 386.29 Aetna Commercial PPO 265.57 percent of total billed charges 265.57 410.43 55 of billed Charges GLOVE POWDER FREE SZ 7 - RED BOX 272 RC inpatient 140.63 70.32 BCBS Louisiana PPO 70.32 percent of total billed charges 70.32 119.54 50% of Eligible Charges GLOVE POWDER FREE SZ 7 - RED BOX 272 RC outpatient 140.63 112.5 BCBS Louisiana PPO 112.5 percent of total billed charges 77.35 119.54 80% of billed charge GLOVE POWDER FREE SZ 7 - RED BOX 272 RC outpatient 140.63 112.5 Cigna Commercial PPO 77.35 percent of total billed charges 77.35 119.54 55% of Billed Charges GLOVE POWDER FREE SZ 7 - RED BOX 272 RC inpatient 140.63 70.32 IMA of Louisiana Commercial PPO 119.54 percent of total billed charges 70.32 119.54 Inpatient Reimbursement at 85% of Billed Charges GLOVE POWDER FREE SZ 7 - RED BOX 272 RC outpatient 140.63 112.5 IMA of Louisiana Commercial PPO 119.54 percent of total billed charges 77.35 119.54 Reimbursement at 85% of billed charges GLOVE POWDER FREE SZ 7 - RED BOX 272 RC outpatient 140.63 112.5 Aetna Commercial PPO 77.35 percent of total billed charges 77.35 119.54 55 of billed Charges K-WIRE 1.25 THREADED/NON-THREADED 272 RC inpatient 138.32 69.16 BCBS Louisiana PPO 69.16 percent of total billed charges 69.16 117.57 50% of Eligible Charges K-WIRE 1.25 THREADED/NON-THREADED 272 RC outpatient 138.32 110.66 BCBS Louisiana PPO 110.66 percent of total billed charges 76.08 117.57 80% of billed charge K-WIRE 1.25 THREADED/NON-THREADED 272 RC outpatient 138.32 110.66 Cigna Commercial PPO 76.08 percent of total billed charges 76.08 117.57 55% of Billed Charges K-WIRE 1.25 THREADED/NON-THREADED 272 RC inpatient 138.32 69.16 IMA of Louisiana Commercial PPO 117.57 percent of total billed charges 69.16 117.57 Inpatient Reimbursement at 85% of Billed Charges K-WIRE 1.25 THREADED/NON-THREADED 272 RC outpatient 138.32 110.66 IMA of Louisiana Commercial PPO 117.57 percent of total billed charges 76.08 117.57 Reimbursement at 85% of billed charges K-WIRE 1.25 THREADED/NON-THREADED 272 RC outpatient 138.32 110.66 Aetna Commercial PPO 76.08 percent of total billed charges 76.08 117.57 55 of billed Charges SKIN ALOE CONDITIONER 270 RC inpatient 127.68 63.84 BCBS Louisiana PPO 63.84 percent of total billed charges 63.84 108.53 50% of Eligible Charges SKIN ALOE CONDITIONER 270 RC outpatient 127.68 102.14 BCBS Louisiana PPO 102.14 percent of total billed charges 70.22 108.53 80% of billed charge SKIN ALOE CONDITIONER 270 RC outpatient 127.68 102.14 Cigna Commercial PPO 70.22 percent of total billed charges 70.22 108.53 55% of Billed Charges SKIN ALOE CONDITIONER 270 RC inpatient 127.68 63.84 IMA of Louisiana Commercial PPO 108.53 percent of total billed charges 63.84 108.53 Inpatient Reimbursement at 85% of Billed Charges SKIN ALOE CONDITIONER 270 RC outpatient 127.68 102.14 IMA of Louisiana Commercial PPO 108.53 percent of total billed charges 70.22 108.53 Reimbursement at 85% of billed charges SKIN ALOE CONDITIONER 270 RC outpatient 127.68 102.14 Aetna Commercial PPO 70.22 percent of total billed charges 70.22 108.53 55 of billed Charges DRILL BIT 2.5MM TWIST - MICRO 272 RC inpatient 91 45.5 BCBS Louisiana PPO 45.5 percent of total billed charges 45.5 77.35 50% of Eligible Charges DRILL BIT 2.5MM TWIST - MICRO 272 RC outpatient 91 72.8 BCBS Louisiana PPO 72.8 percent of total billed charges 50.05 77.35 80% of billed charge DRILL BIT 2.5MM TWIST - MICRO 272 RC outpatient 91 72.8 Cigna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55% of Billed Charges DRILL BIT 2.5MM TWIST - MICRO 272 RC inpatient 91 45.5 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 45.5 77.35 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.5MM TWIST - MICRO 272 RC outpatient 91 72.8 IMA of Louisiana Commercial PPO 77.35 percent of total billed charges 50.05 77.35 Reimbursement at 85% of billed charges DRILL BIT 2.5MM TWIST - MICRO 272 RC outpatient 91 72.8 Aetna Commercial PPO 50.05 percent of total billed charges 50.05 77.35 55 of billed Charges DRILL BIT 3.5MM TWIST - MICRO 272 RC inpatient 155.86 77.93 BCBS Louisiana PPO 77.93 percent of total billed charges 77.93 132.48 50% of Eligible Charges DRILL BIT 3.5MM TWIST - MICRO 272 RC outpatient 155.86 124.69 BCBS Louisiana PPO 124.69 percent of total billed charges 85.72 132.48 80% of billed charge DRILL BIT 3.5MM TWIST - MICRO 272 RC outpatient 155.86 124.69 Cigna Commercial PPO 85.72 percent of total billed charges 85.72 132.48 55% of Billed Charges DRILL BIT 3.5MM TWIST - MICRO 272 RC inpatient 155.86 77.93 IMA of Louisiana Commercial PPO 132.48 percent of total billed charges 77.93 132.48 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 3.5MM TWIST - MICRO 272 RC outpatient 155.86 124.69 IMA of Louisiana Commercial PPO 132.48 percent of total billed charges 85.72 132.48 Reimbursement at 85% of billed charges DRILL BIT 3.5MM TWIST - MICRO 272 RC outpatient 155.86 124.69 Aetna Commercial PPO 85.72 percent of total billed charges 85.72 132.48 55 of billed Charges SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 30MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 BCBS Louisiana PPO 41.68 percent of total billed charges 41.68 70.86 50% of Eligible Charges SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 BCBS Louisiana PPO 66.69 percent of total billed charges 30.84 70.86 80% of billed charge SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Cigna Commercial PPO 48.35 percent of total billed charges 30.84 70.86 58% of Billed Charges/$500 Threshold SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC inpatient 83.36 41.68 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 41.68 70.86 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 IMA of Louisiana Commercial PPO 70.86 percent of total billed charges 30.84 70.86 Reimbursement at 85% of billed charges SCREW 3.5MM CORTEX 55MM - SYNTHES C1713 HCPCS 278 RC outpatient 83.36 66.69 Aetna Commercial PPO 30.84 percent of total billed charges 30.84 70.86 37% Of Billed Charges 2000 K-WIRE 2.0MM SMALL FRAG SET 272 RC inpatient 263.55 131.78 BCBS Louisiana PPO 131.78 percent of total billed charges 131.78 224.02 50% of Eligible Charges K-WIRE 2.0MM SMALL FRAG SET 272 RC outpatient 263.55 210.84 BCBS Louisiana PPO 210.84 percent of total billed charges 144.95 224.02 80% of billed charge K-WIRE 2.0MM SMALL FRAG SET 272 RC outpatient 263.55 210.84 Cigna Commercial PPO 144.95 percent of total billed charges 144.95 224.02 55% of Billed Charges K-WIRE 2.0MM SMALL FRAG SET 272 RC inpatient 263.55 131.78 IMA of Louisiana Commercial PPO 224.02 percent of total billed charges 131.78 224.02 Inpatient Reimbursement at 85% of Billed Charges K-WIRE 2.0MM SMALL FRAG SET 272 RC outpatient 263.55 210.84 IMA of Louisiana Commercial PPO 224.02 percent of total billed charges 144.95 224.02 Reimbursement at 85% of billed charges K-WIRE 2.0MM SMALL FRAG SET 272 RC outpatient 263.55 210.84 Aetna Commercial PPO 144.95 percent of total billed charges 144.95 224.02 55 of billed Charges ENDOTRACH INTRODUCER TU STRT 272 RC inpatient 408.87 204.44 BCBS Louisiana PPO 204.44 percent of total billed charges 204.44 347.54 50% of Eligible Charges ENDOTRACH INTRODUCER TU STRT 272 RC outpatient 408.87 327.1 BCBS Louisiana PPO 327.1 percent of total billed charges 224.88 347.54 80% of billed charge ENDOTRACH INTRODUCER TU STRT 272 RC outpatient 408.87 327.1 Cigna Commercial PPO 224.88 percent of total billed charges 224.88 347.54 55% of Billed Charges ENDOTRACH INTRODUCER TU STRT 272 RC inpatient 408.87 204.44 IMA of Louisiana Commercial PPO 347.54 percent of total billed charges 204.44 347.54 Inpatient Reimbursement at 85% of Billed Charges ENDOTRACH INTRODUCER TU STRT 272 RC outpatient 408.87 327.1 IMA of Louisiana Commercial PPO 347.54 percent of total billed charges 224.88 347.54 Reimbursement at 85% of billed charges ENDOTRACH INTRODUCER TU STRT 272 RC outpatient 408.87 327.1 Aetna Commercial PPO 224.88 percent of total billed charges 224.88 347.54 55 of billed Charges SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 36MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 POUR SPOUT BAG DECANTER 270 RC inpatient 15.4 7.7 BCBS Louisiana PPO 7.7 percent of total billed charges 7.7 13.09 50% of Eligible Charges POUR SPOUT BAG DECANTER 270 RC outpatient 15.4 12.32 BCBS Louisiana PPO 12.32 percent of total billed charges 8.47 13.09 80% of billed charge POUR SPOUT BAG DECANTER 270 RC outpatient 15.4 12.32 Cigna Commercial PPO 8.47 percent of total billed charges 8.47 13.09 55% of Billed Charges POUR SPOUT BAG DECANTER 270 RC inpatient 15.4 7.7 IMA of Louisiana Commercial PPO 13.09 percent of total billed charges 7.7 13.09 Inpatient Reimbursement at 85% of Billed Charges POUR SPOUT BAG DECANTER 270 RC outpatient 15.4 12.32 IMA of Louisiana Commercial PPO 13.09 percent of total billed charges 8.47 13.09 Reimbursement at 85% of billed charges POUR SPOUT BAG DECANTER 270 RC outpatient 15.4 12.32 Aetna Commercial PPO 8.47 percent of total billed charges 8.47 13.09 55 of billed Charges KERLIX LITE 3 272 RC inpatient 29.6 14.8 BCBS Louisiana PPO 14.8 percent of total billed charges 14.8 25.16 50% of Eligible Charges KERLIX LITE 3 272 RC outpatient 29.6 23.68 BCBS Louisiana PPO 23.68 percent of total billed charges 16.28 25.16 80% of billed charge KERLIX LITE 3 272 RC outpatient 29.6 23.68 Cigna Commercial PPO 16.28 percent of total billed charges 16.28 25.16 55% of Billed Charges KERLIX LITE 3 272 RC inpatient 29.6 14.8 IMA of Louisiana Commercial PPO 25.16 percent of total billed charges 14.8 25.16 Inpatient Reimbursement at 85% of Billed Charges KERLIX LITE 3 272 RC outpatient 29.6 23.68 IMA of Louisiana Commercial PPO 25.16 percent of total billed charges 16.28 25.16 Reimbursement at 85% of billed charges KERLIX LITE 3 272 RC outpatient 29.6 23.68 Aetna Commercial PPO 16.28 percent of total billed charges 16.28 25.16 55 of billed Charges SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 BCBS Louisiana PPO 187.17 percent of total billed charges 187.17 318.18 50% of Eligible Charges SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 BCBS Louisiana PPO 299.46 percent of total billed charges 138.5 318.18 80% of billed charge SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Cigna Commercial PPO 217.11 percent of total billed charges 138.5 318.18 58% of Billed Charges/$500 Threshold SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC inpatient 374.33 187.17 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 187.17 318.18 Inpatient Reimbursement at 85% of Billed Charges SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 IMA of Louisiana Commercial PPO 318.18 percent of total billed charges 138.5 318.18 Reimbursement at 85% of billed charges SCREW 3.5MM LOCKING 38MM - SYNTHES C1713 HCPCS 278 RC outpatient 374.33 299.46 Aetna Commercial PPO 138.5 percent of total billed charges 138.5 318.18 37% Of Billed Charges 2000 MAYO NEEDLE 1/2 TAPER 272 RC inpatient 789.45 394.73 BCBS Louisiana PPO 394.73 percent of total billed charges 394.73 671.03 50% of Eligible Charges MAYO NEEDLE 1/2 TAPER 272 RC outpatient 789.45 631.56 BCBS Louisiana PPO 631.56 percent of total billed charges 434.2 671.03 80% of billed charge MAYO NEEDLE 1/2 TAPER 272 RC outpatient 789.45 631.56 Cigna Commercial PPO 434.2 percent of total billed charges 434.2 671.03 55% of Billed Charges MAYO NEEDLE 1/2 TAPER 272 RC inpatient 789.45 394.73 IMA of Louisiana Commercial PPO 671.03 percent of total billed charges 394.73 671.03 Inpatient Reimbursement at 85% of Billed Charges MAYO NEEDLE 1/2 TAPER 272 RC outpatient 789.45 631.56 IMA of Louisiana Commercial PPO 671.03 percent of total billed charges 434.2 671.03 Reimbursement at 85% of billed charges MAYO NEEDLE 1/2 TAPER 272 RC outpatient 789.45 631.56 Aetna Commercial PPO 434.2 percent of total billed charges 434.2 671.03 55 of billed Charges LEG HOLDER PAD DISPOSABLE 270 RC inpatient 513 256.5 BCBS Louisiana PPO 256.5 percent of total billed charges 256.5 436.05 50% of Eligible Charges LEG HOLDER PAD DISPOSABLE 270 RC outpatient 513 410.4 BCBS Louisiana PPO 410.4 percent of total billed charges 282.15 436.05 80% of billed charge LEG HOLDER PAD DISPOSABLE 270 RC outpatient 513 410.4 Cigna Commercial PPO 282.15 percent of total billed charges 282.15 436.05 55% of Billed Charges LEG HOLDER PAD DISPOSABLE 270 RC inpatient 513 256.5 IMA of Louisiana Commercial PPO 436.05 percent of total billed charges 256.5 436.05 Inpatient Reimbursement at 85% of Billed Charges LEG HOLDER PAD DISPOSABLE 270 RC outpatient 513 410.4 IMA of Louisiana Commercial PPO 436.05 percent of total billed charges 282.15 436.05 Reimbursement at 85% of billed charges LEG HOLDER PAD DISPOSABLE 270 RC outpatient 513 410.4 Aetna Commercial PPO 282.15 percent of total billed charges 282.15 436.05 55 of billed Charges SYRINGE BULB IRRIGATION 60CC 272 RC inpatient 211.47 105.74 BCBS Louisiana PPO 105.74 percent of total billed charges 105.74 179.75 50% of Eligible Charges SYRINGE BULB IRRIGATION 60CC 272 RC outpatient 211.47 169.18 BCBS Louisiana PPO 169.18 percent of total billed charges 116.31 179.75 80% of billed charge SYRINGE BULB IRRIGATION 60CC 272 RC outpatient 211.47 169.18 Cigna Commercial PPO 116.31 percent of total billed charges 116.31 179.75 55% of Billed Charges SYRINGE BULB IRRIGATION 60CC 272 RC inpatient 211.47 105.74 IMA of Louisiana Commercial PPO 179.75 percent of total billed charges 105.74 179.75 Inpatient Reimbursement at 85% of Billed Charges SYRINGE BULB IRRIGATION 60CC 272 RC outpatient 211.47 169.18 IMA of Louisiana Commercial PPO 179.75 percent of total billed charges 116.31 179.75 Reimbursement at 85% of billed charges SYRINGE BULB IRRIGATION 60CC 272 RC outpatient 211.47 169.18 Aetna Commercial PPO 116.31 percent of total billed charges 116.31 179.75 55 of billed Charges SUTURE MAXBRAID PE HC-5 272 RC inpatient 132.44 66.22 BCBS Louisiana PPO 66.22 percent of total billed charges 66.22 112.57 50% of Eligible Charges SUTURE MAXBRAID PE HC-5 272 RC outpatient 132.44 105.95 BCBS Louisiana PPO 105.95 percent of total billed charges 72.84 112.57 80% of billed charge SUTURE MAXBRAID PE HC-5 272 RC outpatient 132.44 105.95 Cigna Commercial PPO 72.84 percent of total billed charges 72.84 112.57 55% of Billed Charges SUTURE MAXBRAID PE HC-5 272 RC inpatient 132.44 66.22 IMA of Louisiana Commercial PPO 112.57 percent of total billed charges 66.22 112.57 Inpatient Reimbursement at 85% of Billed Charges SUTURE MAXBRAID PE HC-5 272 RC outpatient 132.44 105.95 IMA of Louisiana Commercial PPO 112.57 percent of total billed charges 72.84 112.57 Reimbursement at 85% of billed charges SUTURE MAXBRAID PE HC-5 272 RC outpatient 132.44 105.95 Aetna Commercial PPO 72.84 percent of total billed charges 72.84 112.57 55 of billed Charges MEASURING CUP GRADUATED 1000CC 270 RC inpatient 681.63 340.82 BCBS Louisiana PPO 340.82 percent of total billed charges 340.82 579.39 50% of Eligible Charges MEASURING CUP GRADUATED 1000CC 270 RC outpatient 681.63 545.3 BCBS Louisiana PPO 545.3 percent of total billed charges 374.9 579.39 80% of billed charge MEASURING CUP GRADUATED 1000CC 270 RC outpatient 681.63 545.3 Cigna Commercial PPO 374.9 percent of total billed charges 374.9 579.39 55% of Billed Charges MEASURING CUP GRADUATED 1000CC 270 RC inpatient 681.63 340.82 IMA of Louisiana Commercial PPO 579.39 percent of total billed charges 340.82 579.39 Inpatient Reimbursement at 85% of Billed Charges MEASURING CUP GRADUATED 1000CC 270 RC outpatient 681.63 545.3 IMA of Louisiana Commercial PPO 579.39 percent of total billed charges 374.9 579.39 Reimbursement at 85% of billed charges MEASURING CUP GRADUATED 1000CC 270 RC outpatient 681.63 545.3 Aetna Commercial PPO 374.9 percent of total billed charges 374.9 579.39 55 of billed Charges NEEDLE SPINAL 25X2 272 RC inpatient 23.24 11.62 BCBS Louisiana PPO 11.62 percent of total billed charges 11.62 19.75 50% of Eligible Charges NEEDLE SPINAL 25X2 272 RC outpatient 23.24 18.59 BCBS Louisiana PPO 18.59 percent of total billed charges 12.78 19.75 80% of billed charge NEEDLE SPINAL 25X2 272 RC outpatient 23.24 18.59 Cigna Commercial PPO 12.78 percent of total billed charges 12.78 19.75 55% of Billed Charges NEEDLE SPINAL 25X2 272 RC inpatient 23.24 11.62 IMA of Louisiana Commercial PPO 19.75 percent of total billed charges 11.62 19.75 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 25X2 272 RC outpatient 23.24 18.59 IMA of Louisiana Commercial PPO 19.75 percent of total billed charges 12.78 19.75 Reimbursement at 85% of billed charges NEEDLE SPINAL 25X2 272 RC outpatient 23.24 18.59 Aetna Commercial PPO 12.78 percent of total billed charges 12.78 19.75 55 of billed Charges SUTURE 1 PDS CT-1 36 Z347H 272 RC inpatient 12.42 6.21 BCBS Louisiana PPO 6.21 percent of total billed charges 6.21 10.56 50% of Eligible Charges SUTURE 1 PDS CT-1 36 Z347H 272 RC outpatient 12.42 9.94 BCBS Louisiana PPO 9.94 percent of total billed charges 6.83 10.56 80% of billed charge SUTURE 1 PDS CT-1 36 Z347H 272 RC outpatient 12.42 9.94 Cigna Commercial PPO 6.83 percent of total billed charges 6.83 10.56 55% of Billed Charges SUTURE 1 PDS CT-1 36 Z347H 272 RC inpatient 12.42 6.21 IMA of Louisiana Commercial PPO 10.56 percent of total billed charges 6.21 10.56 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 PDS CT-1 36 Z347H 272 RC outpatient 12.42 9.94 IMA of Louisiana Commercial PPO 10.56 percent of total billed charges 6.83 10.56 Reimbursement at 85% of billed charges SUTURE 1 PDS CT-1 36 Z347H 272 RC outpatient 12.42 9.94 Aetna Commercial PPO 6.83 percent of total billed charges 6.83 10.56 55 of billed Charges DURASEAL SURAL SEALANT SYSTEM 272 RC inpatient 1589.86 794.93 BCBS Louisiana PPO 794.93 percent of total billed charges 794.93 1351.38 50% of Eligible Charges DURASEAL SURAL SEALANT SYSTEM 272 RC outpatient 1589.86 1271.89 BCBS Louisiana PPO 1271.89 percent of total billed charges 874.42 1351.38 80% of billed charge DURASEAL SURAL SEALANT SYSTEM 272 RC outpatient 1589.86 1271.89 Cigna Commercial PPO 874.42 percent of total billed charges 874.42 1351.38 55% of Billed Charges DURASEAL SURAL SEALANT SYSTEM 272 RC inpatient 1589.86 794.93 IMA of Louisiana Commercial PPO 1351.38 percent of total billed charges 794.93 1351.38 Inpatient Reimbursement at 85% of Billed Charges DURASEAL SURAL SEALANT SYSTEM 272 RC outpatient 1589.86 1271.89 IMA of Louisiana Commercial PPO 1351.38 percent of total billed charges 874.42 1351.38 Reimbursement at 85% of billed charges DURASEAL SURAL SEALANT SYSTEM 272 RC outpatient 1589.86 1271.89 Aetna Commercial PPO 874.42 percent of total billed charges 874.42 1351.38 55 of billed Charges SUTURE 2-0 VICRYL CP-1 J266H 272 RC inpatient 6.88 3.44 BCBS Louisiana PPO 3.44 percent of total billed charges 3.44 5.85 50% of Eligible Charges SUTURE 2-0 VICRYL CP-1 J266H 272 RC outpatient 6.88 5.5 BCBS Louisiana PPO 5.5 percent of total billed charges 3.78 5.85 80% of billed charge SUTURE 2-0 VICRYL CP-1 J266H 272 RC outpatient 6.88 5.5 Cigna Commercial PPO 3.78 percent of total billed charges 3.78 5.85 55% of Billed Charges SUTURE 2-0 VICRYL CP-1 J266H 272 RC inpatient 6.88 3.44 IMA of Louisiana Commercial PPO 5.85 percent of total billed charges 3.44 5.85 Inpatient Reimbursement at 85% of Billed Charges SUTURE 2-0 VICRYL CP-1 J266H 272 RC outpatient 6.88 5.5 IMA of Louisiana Commercial PPO 5.85 percent of total billed charges 3.78 5.85 Reimbursement at 85% of billed charges SUTURE 2-0 VICRYL CP-1 J266H 272 RC outpatient 6.88 5.5 Aetna Commercial PPO 3.78 percent of total billed charges 3.78 5.85 55 of billed Charges TUBING EXT W/ CLIP CLAMP - NELSON 272 RC inpatient 471.2 235.6 BCBS Louisiana PPO 235.6 percent of total billed charges 235.6 400.52 50% of Eligible Charges TUBING EXT W/ CLIP CLAMP - NELSON 272 RC outpatient 471.2 376.96 BCBS Louisiana PPO 376.96 percent of total billed charges 259.16 400.52 80% of billed charge TUBING EXT W/ CLIP CLAMP - NELSON 272 RC outpatient 471.2 376.96 Cigna Commercial PPO 259.16 percent of total billed charges 259.16 400.52 55% of Billed Charges TUBING EXT W/ CLIP CLAMP - NELSON 272 RC inpatient 471.2 235.6 IMA of Louisiana Commercial PPO 400.52 percent of total billed charges 235.6 400.52 Inpatient Reimbursement at 85% of Billed Charges TUBING EXT W/ CLIP CLAMP - NELSON 272 RC outpatient 471.2 376.96 IMA of Louisiana Commercial PPO 400.52 percent of total billed charges 259.16 400.52 Reimbursement at 85% of billed charges TUBING EXT W/ CLIP CLAMP - NELSON 272 RC outpatient 471.2 376.96 Aetna Commercial PPO 259.16 percent of total billed charges 259.16 400.52 55 of billed Charges HEWSON SUTURE RETRIEVER 272 RC inpatient 668.93 334.47 BCBS Louisiana PPO 334.47 percent of total billed charges 334.47 568.59 50% of Eligible Charges HEWSON SUTURE RETRIEVER 272 RC outpatient 668.93 535.14 BCBS Louisiana PPO 535.14 percent of total billed charges 367.91 568.59 80% of billed charge HEWSON SUTURE RETRIEVER 272 RC outpatient 668.93 535.14 Cigna Commercial PPO 367.91 percent of total billed charges 367.91 568.59 55% of Billed Charges HEWSON SUTURE RETRIEVER 272 RC inpatient 668.93 334.47 IMA of Louisiana Commercial PPO 568.59 percent of total billed charges 334.47 568.59 Inpatient Reimbursement at 85% of Billed Charges HEWSON SUTURE RETRIEVER 272 RC outpatient 668.93 535.14 IMA of Louisiana Commercial PPO 568.59 percent of total billed charges 367.91 568.59 Reimbursement at 85% of billed charges HEWSON SUTURE RETRIEVER 272 RC outpatient 668.93 535.14 Aetna Commercial PPO 367.91 percent of total billed charges 367.91 568.59 55 of billed Charges SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 BCBS Louisiana PPO 256.62 percent of total billed charges 256.62 436.25 50% of Eligible Charges SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 BCBS Louisiana PPO 410.59 percent of total billed charges 189.9 436.25 80% of billed charge SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Cigna Commercial PPO 297.68 percent of total billed charges 189.9 436.25 58% of Billed Charges/$500 Threshold SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 513.24 256.62 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 256.62 436.25 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 IMA of Louisiana Commercial PPO 436.25 percent of total billed charges 189.9 436.25 Reimbursement at 85% of billed charges SCREW 4.5MM CANN. PAR 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 513.24 410.59 Aetna Commercial PPO 189.9 percent of total billed charges 189.9 436.25 37% Of Billed Charges 2000 SUTURE FIBERWIRE #2 AR-7200 272 RC inpatient 552 276 BCBS Louisiana PPO 276 percent of total billed charges 276 469.2 50% of Eligible Charges SUTURE FIBERWIRE #2 AR-7200 272 RC outpatient 552 441.6 BCBS Louisiana PPO 441.6 percent of total billed charges 303.6 469.2 80% of billed charge SUTURE FIBERWIRE #2 AR-7200 272 RC outpatient 552 441.6 Cigna Commercial PPO 303.6 percent of total billed charges 303.6 469.2 55% of Billed Charges SUTURE FIBERWIRE #2 AR-7200 272 RC inpatient 552 276 IMA of Louisiana Commercial PPO 469.2 percent of total billed charges 276 469.2 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERWIRE #2 AR-7200 272 RC outpatient 552 441.6 IMA of Louisiana Commercial PPO 469.2 percent of total billed charges 303.6 469.2 Reimbursement at 85% of billed charges SUTURE FIBERWIRE #2 AR-7200 272 RC outpatient 552 441.6 Aetna Commercial PPO 303.6 percent of total billed charges 303.6 469.2 55 of billed Charges MIX EVAC III 272 RC inpatient 702 351 BCBS Louisiana PPO 351 percent of total billed charges 351 596.7 50% of Eligible Charges MIX EVAC III 272 RC outpatient 702 561.6 BCBS Louisiana PPO 561.6 percent of total billed charges 386.1 596.7 80% of billed charge MIX EVAC III 272 RC outpatient 702 561.6 Cigna Commercial PPO 386.1 percent of total billed charges 386.1 596.7 55% of Billed Charges MIX EVAC III 272 RC inpatient 702 351 IMA of Louisiana Commercial PPO 596.7 percent of total billed charges 351 596.7 Inpatient Reimbursement at 85% of Billed Charges MIX EVAC III 272 RC outpatient 702 561.6 IMA of Louisiana Commercial PPO 596.7 percent of total billed charges 386.1 596.7 Reimbursement at 85% of billed charges MIX EVAC III 272 RC outpatient 702 561.6 Aetna Commercial PPO 386.1 percent of total billed charges 386.1 596.7 55 of billed Charges STETHOSCOPE DISPOSABLE YELLOW 270 RC inpatient 56.44 28.22 BCBS Louisiana PPO 28.22 percent of total billed charges 28.22 47.97 50% of Eligible Charges STETHOSCOPE DISPOSABLE YELLOW 270 RC outpatient 56.44 45.15 BCBS Louisiana PPO 45.15 percent of total billed charges 31.04 47.97 80% of billed charge STETHOSCOPE DISPOSABLE YELLOW 270 RC outpatient 56.44 45.15 Cigna Commercial PPO 31.04 percent of total billed charges 31.04 47.97 55% of Billed Charges STETHOSCOPE DISPOSABLE YELLOW 270 RC inpatient 56.44 28.22 IMA of Louisiana Commercial PPO 47.97 percent of total billed charges 28.22 47.97 Inpatient Reimbursement at 85% of Billed Charges STETHOSCOPE DISPOSABLE YELLOW 270 RC outpatient 56.44 45.15 IMA of Louisiana Commercial PPO 47.97 percent of total billed charges 31.04 47.97 Reimbursement at 85% of billed charges STETHOSCOPE DISPOSABLE YELLOW 270 RC outpatient 56.44 45.15 Aetna Commercial PPO 31.04 percent of total billed charges 31.04 47.97 55 of billed Charges KLING MILSTEAD 4 272 RC inpatient 43.24 21.62 BCBS Louisiana PPO 21.62 percent of total billed charges 21.62 36.75 50% of Eligible Charges KLING MILSTEAD 4 272 RC outpatient 43.24 34.59 BCBS Louisiana PPO 34.59 percent of total billed charges 23.78 36.75 80% of billed charge KLING MILSTEAD 4 272 RC outpatient 43.24 34.59 Cigna Commercial PPO 23.78 percent of total billed charges 23.78 36.75 55% of Billed Charges KLING MILSTEAD 4 272 RC inpatient 43.24 21.62 IMA of Louisiana Commercial PPO 36.75 percent of total billed charges 21.62 36.75 Inpatient Reimbursement at 85% of Billed Charges KLING MILSTEAD 4 272 RC outpatient 43.24 34.59 IMA of Louisiana Commercial PPO 36.75 percent of total billed charges 23.78 36.75 Reimbursement at 85% of billed charges KLING MILSTEAD 4 272 RC outpatient 43.24 34.59 Aetna Commercial PPO 23.78 percent of total billed charges 23.78 36.75 55 of billed Charges PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC inpatient 628.86 314.43 BCBS Louisiana PPO 314.43 percent of total billed charges 314.43 534.53 50% of Eligible Charges PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC outpatient 628.86 503.09 BCBS Louisiana PPO 503.09 percent of total billed charges 232.68 534.53 80% of billed charge PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC outpatient 628.86 503.09 Cigna Commercial PPO 364.74 percent of total billed charges 232.68 534.53 58% of Billed Charges/$500 Threshold PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC inpatient 628.86 314.43 IMA of Louisiana Commercial PPO 534.53 percent of total billed charges 314.43 534.53 Inpatient Reimbursement at 85% of Billed Charges PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC outpatient 628.86 503.09 IMA of Louisiana Commercial PPO 534.53 percent of total billed charges 232.68 534.53 Reimbursement at 85% of billed charges PLATE CLOVERLEAF 4 HOLE 104MM - SYN C1713 HCPCS 278 RC outpatient 628.86 503.09 Aetna Commercial PPO 232.68 percent of total billed charges 232.68 534.53 37% Of Billed Charges 2000 BLANKET WARMING FULL BODY 270 RC inpatient 201.81 100.91 BCBS Louisiana PPO 100.91 percent of total billed charges 100.91 171.54 50% of Eligible Charges BLANKET WARMING FULL BODY 270 RC outpatient 201.81 161.45 BCBS Louisiana PPO 161.45 percent of total billed charges 111 171.54 80% of billed charge BLANKET WARMING FULL BODY 270 RC outpatient 201.81 161.45 Cigna Commercial PPO 111 percent of total billed charges 111 171.54 55% of Billed Charges BLANKET WARMING FULL BODY 270 RC inpatient 201.81 100.91 IMA of Louisiana Commercial PPO 171.54 percent of total billed charges 100.91 171.54 Inpatient Reimbursement at 85% of Billed Charges BLANKET WARMING FULL BODY 270 RC outpatient 201.81 161.45 IMA of Louisiana Commercial PPO 171.54 percent of total billed charges 111 171.54 Reimbursement at 85% of billed charges BLANKET WARMING FULL BODY 270 RC outpatient 201.81 161.45 Aetna Commercial PPO 111 percent of total billed charges 111 171.54 55 of billed Charges SABER 30 W/ INTEGRATED CABLE 272 RC inpatient 462.5 231.25 BCBS Louisiana PPO 231.25 percent of total billed charges 231.25 393.13 50% of Eligible Charges SABER 30 W/ INTEGRATED CABLE 272 RC outpatient 462.5 370 BCBS Louisiana PPO 370 percent of total billed charges 254.38 393.13 80% of billed charge SABER 30 W/ INTEGRATED CABLE 272 RC outpatient 462.5 370 Cigna Commercial PPO 254.38 percent of total billed charges 254.38 393.13 55% of Billed Charges SABER 30 W/ INTEGRATED CABLE 272 RC inpatient 462.5 231.25 IMA of Louisiana Commercial PPO 393.13 percent of total billed charges 231.25 393.13 Inpatient Reimbursement at 85% of Billed Charges SABER 30 W/ INTEGRATED CABLE 272 RC outpatient 462.5 370 IMA of Louisiana Commercial PPO 393.13 percent of total billed charges 254.38 393.13 Reimbursement at 85% of billed charges SABER 30 W/ INTEGRATED CABLE 272 RC outpatient 462.5 370 Aetna Commercial PPO 254.38 percent of total billed charges 254.38 393.13 55 of billed Charges GLOVE MICRO PAIN DOCTORS 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges GLOVE MICRO PAIN DOCTORS 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge GLOVE MICRO PAIN DOCTORS 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges GLOVE MICRO PAIN DOCTORS 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges GLOVE MICRO PAIN DOCTORS 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges GLOVE MICRO PAIN DOCTORS 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges BUR OVAL 5.5MM 14AM #14OV55 272 RC inpatient 372.05 186.03 BCBS Louisiana PPO 186.03 percent of total billed charges 186.03 316.24 50% of Eligible Charges BUR OVAL 5.5MM 14AM #14OV55 272 RC outpatient 372.05 297.64 BCBS Louisiana PPO 297.64 percent of total billed charges 204.63 316.24 80% of billed charge BUR OVAL 5.5MM 14AM #14OV55 272 RC outpatient 372.05 297.64 Cigna Commercial PPO 204.63 percent of total billed charges 204.63 316.24 55% of Billed Charges BUR OVAL 5.5MM 14AM #14OV55 272 RC inpatient 372.05 186.03 IMA of Louisiana Commercial PPO 316.24 percent of total billed charges 186.03 316.24 Inpatient Reimbursement at 85% of Billed Charges BUR OVAL 5.5MM 14AM #14OV55 272 RC outpatient 372.05 297.64 IMA of Louisiana Commercial PPO 316.24 percent of total billed charges 204.63 316.24 Reimbursement at 85% of billed charges BUR OVAL 5.5MM 14AM #14OV55 272 RC outpatient 372.05 297.64 Aetna Commercial PPO 204.63 percent of total billed charges 204.63 316.24 55 of billed Charges DRILL BIT 2.0MM - SYNTHES 272 RC inpatient 227.5 113.75 BCBS Louisiana PPO 113.75 percent of total billed charges 113.75 193.38 50% of Eligible Charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 227.5 182 BCBS Louisiana PPO 182 percent of total billed charges 125.13 193.38 80% of billed charge DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 227.5 182 Cigna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55% of Billed Charges DRILL BIT 2.0MM - SYNTHES 272 RC inpatient 227.5 113.75 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 113.75 193.38 Inpatient Reimbursement at 85% of Billed Charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 227.5 182 IMA of Louisiana Commercial PPO 193.38 percent of total billed charges 125.13 193.38 Reimbursement at 85% of billed charges DRILL BIT 2.0MM - SYNTHES 272 RC outpatient 227.5 182 Aetna Commercial PPO 125.13 percent of total billed charges 125.13 193.38 55 of billed Charges CRUTCH BARIATRIC TALL ADULT 270 RC inpatient 317.17 158.59 BCBS Louisiana PPO 158.59 percent of total billed charges 158.59 269.59 50% of Eligible Charges CRUTCH BARIATRIC TALL ADULT 270 RC outpatient 317.17 253.74 BCBS Louisiana PPO 253.74 percent of total billed charges 174.44 269.59 80% of billed charge CRUTCH BARIATRIC TALL ADULT 270 RC outpatient 317.17 253.74 Cigna Commercial PPO 174.44 percent of total billed charges 174.44 269.59 55% of Billed Charges CRUTCH BARIATRIC TALL ADULT 270 RC inpatient 317.17 158.59 IMA of Louisiana Commercial PPO 269.59 percent of total billed charges 158.59 269.59 Inpatient Reimbursement at 85% of Billed Charges CRUTCH BARIATRIC TALL ADULT 270 RC outpatient 317.17 253.74 IMA of Louisiana Commercial PPO 269.59 percent of total billed charges 174.44 269.59 Reimbursement at 85% of billed charges CRUTCH BARIATRIC TALL ADULT 270 RC outpatient 317.17 253.74 Aetna Commercial PPO 174.44 percent of total billed charges 174.44 269.59 55 of billed Charges SHAMPOO DAWNMIST 2 OZ 270 RC inpatient 145.5 72.75 BCBS Louisiana PPO 72.75 percent of total billed charges 72.75 123.68 50% of Eligible Charges SHAMPOO DAWNMIST 2 OZ 270 RC outpatient 145.5 116.4 BCBS Louisiana PPO 116.4 percent of total billed charges 80.03 123.68 80% of billed charge SHAMPOO DAWNMIST 2 OZ 270 RC outpatient 145.5 116.4 Cigna Commercial PPO 80.03 percent of total billed charges 80.03 123.68 55% of Billed Charges SHAMPOO DAWNMIST 2 OZ 270 RC inpatient 145.5 72.75 IMA of Louisiana Commercial PPO 123.68 percent of total billed charges 72.75 123.68 Inpatient Reimbursement at 85% of Billed Charges SHAMPOO DAWNMIST 2 OZ 270 RC outpatient 145.5 116.4 IMA of Louisiana Commercial PPO 123.68 percent of total billed charges 80.03 123.68 Reimbursement at 85% of billed charges SHAMPOO DAWNMIST 2 OZ 270 RC outpatient 145.5 116.4 Aetna Commercial PPO 80.03 percent of total billed charges 80.03 123.68 55 of billed Charges NEEDLE SPINAL 18G X 6 272 RC inpatient 17.52 8.76 BCBS Louisiana PPO 8.76 percent of total billed charges 8.76 14.89 50% of Eligible Charges NEEDLE SPINAL 18G X 6 272 RC outpatient 17.52 14.02 BCBS Louisiana PPO 14.02 percent of total billed charges 9.64 14.89 80% of billed charge NEEDLE SPINAL 18G X 6 272 RC outpatient 17.52 14.02 Cigna Commercial PPO 9.64 percent of total billed charges 9.64 14.89 55% of Billed Charges NEEDLE SPINAL 18G X 6 272 RC inpatient 17.52 8.76 IMA of Louisiana Commercial PPO 14.89 percent of total billed charges 8.76 14.89 Inpatient Reimbursement at 85% of Billed Charges NEEDLE SPINAL 18G X 6 272 RC outpatient 17.52 14.02 IMA of Louisiana Commercial PPO 14.89 percent of total billed charges 9.64 14.89 Reimbursement at 85% of billed charges NEEDLE SPINAL 18G X 6 272 RC outpatient 17.52 14.02 Aetna Commercial PPO 9.64 percent of total billed charges 9.64 14.89 55 of billed Charges EPIDURAL PULSATOR SYRINGE 272 RC inpatient 22.26 11.13 BCBS Louisiana PPO 11.13 percent of total billed charges 11.13 18.92 50% of Eligible Charges EPIDURAL PULSATOR SYRINGE 272 RC outpatient 22.26 17.81 BCBS Louisiana PPO 17.81 percent of total billed charges 12.24 18.92 80% of billed charge EPIDURAL PULSATOR SYRINGE 272 RC outpatient 22.26 17.81 Cigna Commercial PPO 12.24 percent of total billed charges 12.24 18.92 55% of Billed Charges EPIDURAL PULSATOR SYRINGE 272 RC inpatient 22.26 11.13 IMA of Louisiana Commercial PPO 18.92 percent of total billed charges 11.13 18.92 Inpatient Reimbursement at 85% of Billed Charges EPIDURAL PULSATOR SYRINGE 272 RC outpatient 22.26 17.81 IMA of Louisiana Commercial PPO 18.92 percent of total billed charges 12.24 18.92 Reimbursement at 85% of billed charges EPIDURAL PULSATOR SYRINGE 272 RC outpatient 22.26 17.81 Aetna Commercial PPO 12.24 percent of total billed charges 12.24 18.92 55 of billed Charges DRAPE SHOULDER GOOGE 272 RC inpatient 95.16 47.58 BCBS Louisiana PPO 47.58 percent of total billed charges 47.58 80.89 50% of Eligible Charges DRAPE SHOULDER GOOGE 272 RC outpatient 95.16 76.13 BCBS Louisiana PPO 76.13 percent of total billed charges 52.34 80.89 80% of billed charge DRAPE SHOULDER GOOGE 272 RC outpatient 95.16 76.13 Cigna Commercial PPO 52.34 percent of total billed charges 52.34 80.89 55% of Billed Charges DRAPE SHOULDER GOOGE 272 RC inpatient 95.16 47.58 IMA of Louisiana Commercial PPO 80.89 percent of total billed charges 47.58 80.89 Inpatient Reimbursement at 85% of Billed Charges DRAPE SHOULDER GOOGE 272 RC outpatient 95.16 76.13 IMA of Louisiana Commercial PPO 80.89 percent of total billed charges 52.34 80.89 Reimbursement at 85% of billed charges DRAPE SHOULDER GOOGE 272 RC outpatient 95.16 76.13 Aetna Commercial PPO 52.34 percent of total billed charges 52.34 80.89 55 of billed Charges EXT SET SM BORE - REMI TUBING 272 RC inpatient 7.66 3.83 BCBS Louisiana PPO 3.83 percent of total billed charges 3.83 6.51 50% of Eligible Charges EXT SET SM BORE - REMI TUBING 272 RC outpatient 7.66 6.13 BCBS Louisiana PPO 6.13 percent of total billed charges 4.21 6.51 80% of billed charge EXT SET SM BORE - REMI TUBING 272 RC outpatient 7.66 6.13 Cigna Commercial PPO 4.21 percent of total billed charges 4.21 6.51 55% of Billed Charges EXT SET SM BORE - REMI TUBING 272 RC inpatient 7.66 3.83 IMA of Louisiana Commercial PPO 6.51 percent of total billed charges 3.83 6.51 Inpatient Reimbursement at 85% of Billed Charges EXT SET SM BORE - REMI TUBING 272 RC outpatient 7.66 6.13 IMA of Louisiana Commercial PPO 6.51 percent of total billed charges 4.21 6.51 Reimbursement at 85% of billed charges EXT SET SM BORE - REMI TUBING 272 RC outpatient 7.66 6.13 Aetna Commercial PPO 4.21 percent of total billed charges 4.21 6.51 55 of billed Charges SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC inpatient 115.71 57.86 BCBS Louisiana PPO 57.86 percent of total billed charges 57.86 98.35 50% of Eligible Charges SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 BCBS Louisiana PPO 92.57 percent of total billed charges 42.81 98.35 80% of billed charge SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 Cigna Commercial PPO 67.11 percent of total billed charges 42.81 98.35 58% of Billed Charges/$500 Threshold SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC inpatient 115.71 57.86 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 57.86 98.35 Inpatient Reimbursement at 85% of Billed Charges SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 IMA of Louisiana Commercial PPO 98.35 percent of total billed charges 42.81 98.35 Reimbursement at 85% of billed charges SCREW 6.5MM CANC. 65MM - SYNTHES C1713 HCPCS 278 RC outpatient 115.71 92.57 Aetna Commercial PPO 42.81 percent of total billed charges 42.81 98.35 37% Of Billed Charges 2000 CPM PATIENT CARE KIT 270 RC inpatient 60 30 BCBS Louisiana PPO 30 percent of total billed charges 30 51 50% of Eligible Charges CPM PATIENT CARE KIT 270 RC outpatient 60 48 BCBS Louisiana PPO 48 percent of total billed charges 33 51 80% of billed charge CPM PATIENT CARE KIT 270 RC outpatient 60 48 Cigna Commercial PPO 33 percent of total billed charges 33 51 55% of Billed Charges CPM PATIENT CARE KIT 270 RC inpatient 60 30 IMA of Louisiana Commercial PPO 51 percent of total billed charges 30 51 Inpatient Reimbursement at 85% of Billed Charges CPM PATIENT CARE KIT 270 RC outpatient 60 48 IMA of Louisiana Commercial PPO 51 percent of total billed charges 33 51 Reimbursement at 85% of billed charges CPM PATIENT CARE KIT 270 RC outpatient 60 48 Aetna Commercial PPO 33 percent of total billed charges 33 51 55 of billed Charges CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC inpatient 537.64 268.82 BCBS Louisiana PPO 268.82 percent of total billed charges 268.82 456.99 50% of Eligible Charges CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC outpatient 537.64 430.11 BCBS Louisiana PPO 430.11 percent of total billed charges 295.7 456.99 80% of billed charge CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC outpatient 537.64 430.11 Cigna Commercial PPO 295.7 percent of total billed charges 295.7 456.99 55% of Billed Charges CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC inpatient 537.64 268.82 IMA of Louisiana Commercial PPO 456.99 percent of total billed charges 268.82 456.99 Inpatient Reimbursement at 85% of Billed Charges CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC outpatient 537.64 430.11 IMA of Louisiana Commercial PPO 456.99 percent of total billed charges 295.7 456.99 Reimbursement at 85% of billed charges CATHETER COUDE LTX/TEF 20FR 5CC - GU DR 272 RC outpatient 537.64 430.11 Aetna Commercial PPO 295.7 percent of total billed charges 295.7 456.99 55 of billed Charges F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC inpatient 1750 875 BCBS Louisiana PPO 875 percent of total billed charges 875 1487.5 50% of Eligible Charges F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC outpatient 1750 1400 BCBS Louisiana PPO 1400 percent of total billed charges 647.5 1487.5 80% of billed charge F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC outpatient 1750 1400 Cigna Commercial PPO 1015 percent of total billed charges 647.5 1487.5 58% of Billed Charges/$500 Threshold F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC inpatient 1750 875 IMA of Louisiana Commercial PPO 1487.5 percent of total billed charges 875 1487.5 Inpatient Reimbursement at 85% of Billed Charges F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC outpatient 1750 1400 IMA of Louisiana Commercial PPO 1487.5 percent of total billed charges 647.5 1487.5 Reimbursement at 85% of billed charges F.F. POSTERIOR TIBIALIS TENDON C1762 HCPCS 278 RC outpatient 1750 1400 Aetna Commercial PPO 647.5 percent of total billed charges 647.5 1487.5 37% Of Billed Charges 2000 BUR #MC16 272 RC inpatient 390 195 BCBS Louisiana PPO 195 percent of total billed charges 195 331.5 50% of Eligible Charges BUR #MC16 272 RC outpatient 390 312 BCBS Louisiana PPO 312 percent of total billed charges 214.5 331.5 80% of billed charge BUR #MC16 272 RC outpatient 390 312 Cigna Commercial PPO 214.5 percent of total billed charges 214.5 331.5 55% of Billed Charges BUR #MC16 272 RC inpatient 390 195 IMA of Louisiana Commercial PPO 331.5 percent of total billed charges 195 331.5 Inpatient Reimbursement at 85% of Billed Charges BUR #MC16 272 RC outpatient 390 312 IMA of Louisiana Commercial PPO 331.5 percent of total billed charges 214.5 331.5 Reimbursement at 85% of billed charges BUR #MC16 272 RC outpatient 390 312 Aetna Commercial PPO 214.5 percent of total billed charges 214.5 331.5 55 of billed Charges K-WIRE NON-THREADED .054 272 RC inpatient 131.25 65.63 BCBS Louisiana PPO 65.63 percent of total billed charges 65.63 111.56 50% of Eligible Charges K-WIRE NON-THREADED .054 272 RC outpatient 131.25 105 BCBS Louisiana PPO 105 percent of total billed charges 72.19 111.56 80% of billed charge K-WIRE NON-THREADED .054 272 RC outpatient 131.25 105 Cigna Commercial PPO 72.19 percent of total billed charges 72.19 111.56 55% of Billed Charges K-WIRE NON-THREADED .054 272 RC inpatient 131.25 65.63 IMA of Louisiana Commercial PPO 111.56 percent of total billed charges 65.63 111.56 Inpatient Reimbursement at 85% of Billed Charges K-WIRE NON-THREADED .054 272 RC outpatient 131.25 105 IMA of Louisiana Commercial PPO 111.56 percent of total billed charges 72.19 111.56 Reimbursement at 85% of billed charges K-WIRE NON-THREADED .054 272 RC outpatient 131.25 105 Aetna Commercial PPO 72.19 percent of total billed charges 72.19 111.56 55 of billed Charges BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC inpatient 297.5 148.75 BCBS Louisiana PPO 148.75 percent of total billed charges 148.75 252.88 50% of Eligible Charges BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC outpatient 297.5 238 BCBS Louisiana PPO 238 percent of total billed charges 110.08 252.88 80% of billed charge BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC outpatient 297.5 238 Cigna Commercial PPO 172.55 percent of total billed charges 110.08 252.88 58% of Billed Charges/$500 Threshold BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC inpatient 297.5 148.75 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 148.75 252.88 Inpatient Reimbursement at 85% of Billed Charges BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC outpatient 297.5 238 IMA of Louisiana Commercial PPO 252.88 percent of total billed charges 110.08 252.88 Reimbursement at 85% of billed charges BTB QUAD/HEMI GRAFT 10MM C1762 HCPCS 278 RC outpatient 297.5 238 Aetna Commercial PPO 110.08 percent of total billed charges 110.08 252.88 37% Of Billed Charges 2000 GENERAL ANES. - SUPPLIES 270 RC inpatient 139.78 69.89 BCBS Louisiana PPO 69.89 percent of total billed charges 69.89 118.81 50% of Eligible Charges GENERAL ANES. - SUPPLIES 270 RC outpatient 139.78 111.82 BCBS Louisiana PPO 111.82 percent of total billed charges 76.88 118.81 80% of billed charge GENERAL ANES. - SUPPLIES 270 RC outpatient 139.78 111.82 Cigna Commercial PPO 76.88 percent of total billed charges 76.88 118.81 55% of Billed Charges GENERAL ANES. - SUPPLIES 270 RC inpatient 139.78 69.89 IMA of Louisiana Commercial PPO 118.81 percent of total billed charges 69.89 118.81 Inpatient Reimbursement at 85% of Billed Charges GENERAL ANES. - SUPPLIES 270 RC outpatient 139.78 111.82 IMA of Louisiana Commercial PPO 118.81 percent of total billed charges 76.88 118.81 Reimbursement at 85% of billed charges GENERAL ANES. - SUPPLIES 270 RC outpatient 139.78 111.82 Aetna Commercial PPO 76.88 percent of total billed charges 76.88 118.81 55 of billed Charges NEEDLE NERVE STIM 22G X 2 #333642 272 RC inpatient 64.88 32.44 BCBS Louisiana PPO 32.44 percent of total billed charges 32.44 55.15 50% of Eligible Charges NEEDLE NERVE STIM 22G X 2 #333642 272 RC outpatient 64.88 51.9 BCBS Louisiana PPO 51.9 percent of total billed charges 35.68 55.15 80% of billed charge NEEDLE NERVE STIM 22G X 2 #333642 272 RC outpatient 64.88 51.9 Cigna Commercial PPO 35.68 percent of total billed charges 35.68 55.15 55% of Billed Charges NEEDLE NERVE STIM 22G X 2 #333642 272 RC inpatient 64.88 32.44 IMA of Louisiana Commercial PPO 55.15 percent of total billed charges 32.44 55.15 Inpatient Reimbursement at 85% of Billed Charges NEEDLE NERVE STIM 22G X 2 #333642 272 RC outpatient 64.88 51.9 IMA of Louisiana Commercial PPO 55.15 percent of total billed charges 35.68 55.15 Reimbursement at 85% of billed charges NEEDLE NERVE STIM 22G X 2 #333642 272 RC outpatient 64.88 51.9 Aetna Commercial PPO 35.68 percent of total billed charges 35.68 55.15 55 of billed Charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC inpatient 611.75 305.88 BCBS Louisiana PPO 305.88 percent of total billed charges 305.88 519.99 50% of Eligible Charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC outpatient 611.75 489.4 BCBS Louisiana PPO 489.4 percent of total billed charges 336.46 1300 80% of billed charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC outpatient 611.75 489.4 Cigna Commercial PPO 336.46 percent of total billed charges 336.46 1300 55% of Billed Charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC inpatient 611.75 305.88 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 305.88 519.99 Inpatient Reimbursement at 85% of Billed Charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC outpatient 611.75 489.4 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 336.46 1300 Reimbursement at 85% of billed charges NERVOUS SYSTEM SURGERY 64999 CPT 360 RC outpatient 611.75 489.4 Aetna Commercial PPO 1300 fee schedule 336.46 1300 Case Rate IONM IN OR 15 MIN 95940 CPT 360 RC inpatient 477.3 238.65 BCBS Louisiana PPO 238.65 percent of total billed charges 238.65 405.71 50% of Eligible Charges IONM IN OR 15 MIN 95940 CPT 360 RC outpatient 477.3 381.84 BCBS Louisiana PPO 381.84 percent of total billed charges 262.52 405.71 80% of billed charge IONM IN OR 15 MIN 95940 CPT 360 RC outpatient 477.3 381.84 Cigna Commercial PPO 262.52 percent of total billed charges 262.52 405.71 55% of Billed Charges IONM IN OR 15 MIN 95940 CPT 360 RC inpatient 477.3 238.65 IMA of Louisiana Commercial PPO 405.71 percent of total billed charges 238.65 405.71 Inpatient Reimbursement at 85% of Billed Charges IONM IN OR 15 MIN 95940 CPT 360 RC outpatient 477.3 381.84 IMA of Louisiana Commercial PPO 405.71 percent of total billed charges 262.52 405.71 Reimbursement at 85% of billed charges IONM IN OR 15 MIN 95940 CPT 360 RC outpatient 477.3 381.84 Aetna Commercial PPO 262.52 percent of total billed charges 262.52 405.71 55 of billed Charges PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" inpatient 77.58 38.79 BCBS Louisiana PPO 38.79 percent of total billed charges 38.79 65.94 50% of Eligible Charges PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" outpatient 77.58 62.06 BCBS Louisiana PPO 62.06 percent of total billed charges 61.9 85 80% of billed charge PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" outpatient 77.58 62.06 Cigna Commercial PPO 85 other 61.9 85 63% of Billed Charges PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" inpatient 77.58 38.79 IMA of Louisiana Commercial PPO 65.94 percent of total billed charges 38.79 65.94 Inpatient Reimbursement at 85% of Billed Charges PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" outpatient 77.58 62.06 IMA of Louisiana Commercial PPO 65.94 percent of total billed charges 61.9 85 Reimbursement at 85% of billed charges PT THERAPEUTIC EXERCISE 97110 CPT 421 RC "GP,59" outpatient 77.58 62.06 Aetna Commercial PPO 61.9 fee schedule 61.9 85 200% Of Aetna Market Fee Schedule PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" inpatient 46.38 23.19 BCBS Louisiana PPO 23.19 percent of total billed charges 23.19 39.42 50% of Eligible Charges PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" outpatient 46.38 37.1 BCBS Louisiana PPO 37.1 percent of total billed charges 33.7 85 80% of billed charge PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" outpatient 46.38 37.1 Cigna Commercial PPO 85 other 33.7 85 63% of Billed Charges PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" inpatient 46.38 23.19 IMA of Louisiana Commercial PPO 39.42 percent of total billed charges 23.19 39.42 Inpatient Reimbursement at 85% of Billed Charges PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" outpatient 46.38 37.1 IMA of Louisiana Commercial PPO 39.42 percent of total billed charges 33.7 85 Reimbursement at 85% of billed charges PT GROUP THERAPEUTIC EXERCISE 97150 CPT 421 RC "GP,59" outpatient 46.38 37.1 Aetna Commercial PPO 33.7 fee schedule 33.7 85 200% Of Aetna Market Fee Schedule WAND SHORT BEVEL 35 272 RC inpatient 462.5 231.25 BCBS Louisiana PPO 231.25 percent of total billed charges 231.25 393.13 50% of Eligible Charges WAND SHORT BEVEL 35 272 RC outpatient 462.5 370 BCBS Louisiana PPO 370 percent of total billed charges 254.38 393.13 80% of billed charge WAND SHORT BEVEL 35 272 RC outpatient 462.5 370 Cigna Commercial PPO 254.38 percent of total billed charges 254.38 393.13 55% of Billed Charges WAND SHORT BEVEL 35 272 RC inpatient 462.5 231.25 IMA of Louisiana Commercial PPO 393.13 percent of total billed charges 231.25 393.13 Inpatient Reimbursement at 85% of Billed Charges WAND SHORT BEVEL 35 272 RC outpatient 462.5 370 IMA of Louisiana Commercial PPO 393.13 percent of total billed charges 254.38 393.13 Reimbursement at 85% of billed charges WAND SHORT BEVEL 35 272 RC outpatient 462.5 370 Aetna Commercial PPO 254.38 percent of total billed charges 254.38 393.13 55 of billed Charges VESSEL LOOP MINI 272 RC inpatient 77.28 38.64 BCBS Louisiana PPO 38.64 percent of total billed charges 38.64 65.69 50% of Eligible Charges VESSEL LOOP MINI 272 RC outpatient 77.28 61.82 BCBS Louisiana PPO 61.82 percent of total billed charges 42.5 65.69 80% of billed charge VESSEL LOOP MINI 272 RC outpatient 77.28 61.82 Cigna Commercial PPO 42.5 percent of total billed charges 42.5 65.69 55% of Billed Charges VESSEL LOOP MINI 272 RC inpatient 77.28 38.64 IMA of Louisiana Commercial PPO 65.69 percent of total billed charges 38.64 65.69 Inpatient Reimbursement at 85% of Billed Charges VESSEL LOOP MINI 272 RC outpatient 77.28 61.82 IMA of Louisiana Commercial PPO 65.69 percent of total billed charges 42.5 65.69 Reimbursement at 85% of billed charges VESSEL LOOP MINI 272 RC outpatient 77.28 61.82 Aetna Commercial PPO 42.5 percent of total billed charges 42.5 65.69 55 of billed Charges GLOVE ORTHO 8.5 272 RC inpatient 157.99 79 BCBS Louisiana PPO 79 percent of total billed charges 79 134.29 50% of Eligible Charges GLOVE ORTHO 8.5 272 RC outpatient 157.99 126.39 BCBS Louisiana PPO 126.39 percent of total billed charges 86.89 134.29 80% of billed charge GLOVE ORTHO 8.5 272 RC outpatient 157.99 126.39 Cigna Commercial PPO 86.89 percent of total billed charges 86.89 134.29 55% of Billed Charges GLOVE ORTHO 8.5 272 RC inpatient 157.99 79 IMA of Louisiana Commercial PPO 134.29 percent of total billed charges 79 134.29 Inpatient Reimbursement at 85% of Billed Charges GLOVE ORTHO 8.5 272 RC outpatient 157.99 126.39 IMA of Louisiana Commercial PPO 134.29 percent of total billed charges 86.89 134.29 Reimbursement at 85% of billed charges GLOVE ORTHO 8.5 272 RC outpatient 157.99 126.39 Aetna Commercial PPO 86.89 percent of total billed charges 86.89 134.29 55 of billed Charges SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC inpatient 602.82 301.41 BCBS Louisiana PPO 301.41 percent of total billed charges 301.41 512.4 50% of Eligible Charges SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC outpatient 602.82 482.26 BCBS Louisiana PPO 482.26 percent of total billed charges 331.55 512.4 80% of billed charge SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC outpatient 602.82 482.26 Cigna Commercial PPO 331.55 percent of total billed charges 331.55 512.4 55% of Billed Charges SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC inpatient 602.82 301.41 IMA of Louisiana Commercial PPO 512.4 percent of total billed charges 301.41 512.4 Inpatient Reimbursement at 85% of Billed Charges SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC outpatient 602.82 482.26 IMA of Louisiana Commercial PPO 512.4 percent of total billed charges 331.55 512.4 Reimbursement at 85% of billed charges SUTURE STRATAFIX/QUILL 2-0 MONODERM 272 RC outpatient 602.82 482.26 Aetna Commercial PPO 331.55 percent of total billed charges 331.55 512.4 55 of billed Charges RF NEEDLE 22G 5CM 5MM 272 RC inpatient 450 225 BCBS Louisiana PPO 225 percent of total billed charges 225 382.5 50% of Eligible Charges RF NEEDLE 22G 5CM 5MM 272 RC outpatient 450 360 BCBS Louisiana PPO 360 percent of total billed charges 247.5 382.5 80% of billed charge RF NEEDLE 22G 5CM 5MM 272 RC outpatient 450 360 Cigna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55% of Billed Charges RF NEEDLE 22G 5CM 5MM 272 RC inpatient 450 225 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 225 382.5 Inpatient Reimbursement at 85% of Billed Charges RF NEEDLE 22G 5CM 5MM 272 RC outpatient 450 360 IMA of Louisiana Commercial PPO 382.5 percent of total billed charges 247.5 382.5 Reimbursement at 85% of billed charges RF NEEDLE 22G 5CM 5MM 272 RC outpatient 450 360 Aetna Commercial PPO 247.5 percent of total billed charges 247.5 382.5 55 of billed Charges DUAL CONNECTOR FOR POLAR CARE 270 RC inpatient 77.24 38.62 BCBS Louisiana PPO 38.62 percent of total billed charges 38.62 65.65 50% of Eligible Charges DUAL CONNECTOR FOR POLAR CARE 270 RC outpatient 77.24 61.79 BCBS Louisiana PPO 61.79 percent of total billed charges 42.48 65.65 80% of billed charge DUAL CONNECTOR FOR POLAR CARE 270 RC outpatient 77.24 61.79 Cigna Commercial PPO 42.48 percent of total billed charges 42.48 65.65 55% of Billed Charges DUAL CONNECTOR FOR POLAR CARE 270 RC inpatient 77.24 38.62 IMA of Louisiana Commercial PPO 65.65 percent of total billed charges 38.62 65.65 Inpatient Reimbursement at 85% of Billed Charges DUAL CONNECTOR FOR POLAR CARE 270 RC outpatient 77.24 61.79 IMA of Louisiana Commercial PPO 65.65 percent of total billed charges 42.48 65.65 Reimbursement at 85% of billed charges DUAL CONNECTOR FOR POLAR CARE 270 RC outpatient 77.24 61.79 Aetna Commercial PPO 42.48 percent of total billed charges 42.48 65.65 55 of billed Charges ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC inpatient 595 297.5 BCBS Louisiana PPO 297.5 percent of total billed charges 297.5 505.75 50% of Eligible Charges ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC outpatient 595 476 BCBS Louisiana PPO 476 percent of total billed charges 220.15 505.75 80% of billed charge ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC outpatient 595 476 Cigna Commercial PPO 345.1 percent of total billed charges 220.15 505.75 58% of Billed Charges/$500 Threshold ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC inpatient 595 297.5 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 297.5 505.75 Inpatient Reimbursement at 85% of Billed Charges ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC outpatient 595 476 IMA of Louisiana Commercial PPO 505.75 percent of total billed charges 220.15 505.75 Reimbursement at 85% of billed charges ANCHOR HEALICOIL 5.5MM #72203379- S&N EN C1713 HCPCS 278 RC outpatient 595 476 Aetna Commercial PPO 220.15 percent of total billed charges 220.15 505.75 37% Of Billed Charges 2000 ULTRASOUND GEL STERILE 272 RC inpatient 5.72 2.86 BCBS Louisiana PPO 2.86 percent of total billed charges 2.86 4.86 50% of Eligible Charges ULTRASOUND GEL STERILE 272 RC outpatient 5.72 4.58 BCBS Louisiana PPO 4.58 percent of total billed charges 3.15 4.86 80% of billed charge ULTRASOUND GEL STERILE 272 RC outpatient 5.72 4.58 Cigna Commercial PPO 3.15 percent of total billed charges 3.15 4.86 55% of Billed Charges ULTRASOUND GEL STERILE 272 RC inpatient 5.72 2.86 IMA of Louisiana Commercial PPO 4.86 percent of total billed charges 2.86 4.86 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND GEL STERILE 272 RC outpatient 5.72 4.58 IMA of Louisiana Commercial PPO 4.86 percent of total billed charges 3.15 4.86 Reimbursement at 85% of billed charges ULTRASOUND GEL STERILE 272 RC outpatient 5.72 4.58 Aetna Commercial PPO 3.15 percent of total billed charges 3.15 4.86 55 of billed Charges ULTRASOUND PROBE COVER 272 RC inpatient 61.36 30.68 BCBS Louisiana PPO 30.68 percent of total billed charges 30.68 52.16 50% of Eligible Charges ULTRASOUND PROBE COVER 272 RC outpatient 61.36 49.09 BCBS Louisiana PPO 49.09 percent of total billed charges 33.75 52.16 80% of billed charge ULTRASOUND PROBE COVER 272 RC outpatient 61.36 49.09 Cigna Commercial PPO 33.75 percent of total billed charges 33.75 52.16 55% of Billed Charges ULTRASOUND PROBE COVER 272 RC inpatient 61.36 30.68 IMA of Louisiana Commercial PPO 52.16 percent of total billed charges 30.68 52.16 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND PROBE COVER 272 RC outpatient 61.36 49.09 IMA of Louisiana Commercial PPO 52.16 percent of total billed charges 33.75 52.16 Reimbursement at 85% of billed charges ULTRASOUND PROBE COVER 272 RC outpatient 61.36 49.09 Aetna Commercial PPO 33.75 percent of total billed charges 33.75 52.16 55 of billed Charges STABILIZATION SHOULDER KIT - S&N ENDO 272 RC inpatient 893.7 446.85 BCBS Louisiana PPO 446.85 percent of total billed charges 446.85 759.65 50% of Eligible Charges STABILIZATION SHOULDER KIT - S&N ENDO 272 RC outpatient 893.7 714.96 BCBS Louisiana PPO 714.96 percent of total billed charges 491.54 759.65 80% of billed charge STABILIZATION SHOULDER KIT - S&N ENDO 272 RC outpatient 893.7 714.96 Cigna Commercial PPO 491.54 percent of total billed charges 491.54 759.65 55% of Billed Charges STABILIZATION SHOULDER KIT - S&N ENDO 272 RC inpatient 893.7 446.85 IMA of Louisiana Commercial PPO 759.65 percent of total billed charges 446.85 759.65 Inpatient Reimbursement at 85% of Billed Charges STABILIZATION SHOULDER KIT - S&N ENDO 272 RC outpatient 893.7 714.96 IMA of Louisiana Commercial PPO 759.65 percent of total billed charges 491.54 759.65 Reimbursement at 85% of billed charges STABILIZATION SHOULDER KIT - S&N ENDO 272 RC outpatient 893.7 714.96 Aetna Commercial PPO 491.54 percent of total billed charges 491.54 759.65 55 of billed Charges ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC inpatient 577.6 288.8 BCBS Louisiana PPO 288.8 percent of total billed charges 288.8 490.96 50% of Eligible Charges ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC outpatient 577.6 462.08 BCBS Louisiana PPO 462.08 percent of total billed charges 213.71 490.96 80% of billed charge ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC outpatient 577.6 462.08 Cigna Commercial PPO 335.01 percent of total billed charges 213.71 490.96 58% of Billed Charges/$500 Threshold ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC inpatient 577.6 288.8 IMA of Louisiana Commercial PPO 490.96 percent of total billed charges 288.8 490.96 Inpatient Reimbursement at 85% of Billed Charges ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC outpatient 577.6 462.08 IMA of Louisiana Commercial PPO 490.96 percent of total billed charges 213.71 490.96 Reimbursement at 85% of billed charges ANCHOR 5.0MM W/ NEEDLE C1713 HCPCS 278 RC outpatient 577.6 462.08 Aetna Commercial PPO 213.71 percent of total billed charges 213.71 490.96 37% Of Billed Charges 2000 BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC inpatient 124.32 62.16 BCBS Louisiana PPO 62.16 percent of total billed charges 62.16 105.67 50% of Eligible Charges BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC outpatient 124.32 99.46 BCBS Louisiana PPO 99.46 percent of total billed charges 68.38 105.67 80% of billed charge BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC outpatient 124.32 99.46 Cigna Commercial PPO 68.38 percent of total billed charges 68.38 105.67 55% of Billed Charges BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC inpatient 124.32 62.16 IMA of Louisiana Commercial PPO 105.67 percent of total billed charges 62.16 105.67 Inpatient Reimbursement at 85% of Billed Charges BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC outpatient 124.32 99.46 IMA of Louisiana Commercial PPO 105.67 percent of total billed charges 68.38 105.67 Reimbursement at 85% of billed charges BUTTERFLY NEEDLE 23G COLLECTION SET 272 RC outpatient 124.32 99.46 Aetna Commercial PPO 68.38 percent of total billed charges 68.38 105.67 55 of billed Charges INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC inpatient 2512.5 1256.25 BCBS Louisiana PPO 1256.25 percent of total billed charges 1256.25 2135.63 50% of Eligible Charges INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC outpatient 2512.5 2010 BCBS Louisiana PPO 2010 percent of total billed charges 929.63 2135.63 80% of billed charge INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC outpatient 2512.5 2010 Cigna Commercial PPO 1457.25 percent of total billed charges 929.63 2135.63 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC inpatient 2512.5 1256.25 IMA of Louisiana Commercial PPO 2135.63 percent of total billed charges 1256.25 2135.63 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC outpatient 2512.5 2010 IMA of Louisiana Commercial PPO 2135.63 percent of total billed charges 929.63 2135.63 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT X SMALL-SHS PRODUC C1713 HCPCS 278 RC outpatient 2512.5 2010 Aetna Commercial PPO 929.63 percent of total billed charges 929.63 2135.63 37% Of Billed Charges 2000 NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC inpatient 484.05 242.03 BCBS Louisiana PPO 242.03 percent of total billed charges 242.03 411.44 50% of Eligible Charges NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC outpatient 484.05 387.24 BCBS Louisiana PPO 387.24 percent of total billed charges 266.23 411.44 80% of billed charge NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC outpatient 484.05 387.24 Cigna Commercial PPO 266.23 percent of total billed charges 266.23 411.44 55% of Billed Charges NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC inpatient 484.05 242.03 IMA of Louisiana Commercial PPO 411.44 percent of total billed charges 242.03 411.44 Inpatient Reimbursement at 85% of Billed Charges NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC outpatient 484.05 387.24 IMA of Louisiana Commercial PPO 411.44 percent of total billed charges 266.23 411.44 Reimbursement at 85% of billed charges NEEDLE KEITH STRAIGHT 1 3/4 (MILSTEAD) 272 RC outpatient 484.05 387.24 Aetna Commercial PPO 266.23 percent of total billed charges 266.23 411.44 55 of billed Charges AQUAMANTYS BIPOLAR SEALER 6.0 272 RC inpatient 633.5 316.75 BCBS Louisiana PPO 316.75 percent of total billed charges 316.75 538.48 50% of Eligible Charges AQUAMANTYS BIPOLAR SEALER 6.0 272 RC outpatient 633.5 506.8 BCBS Louisiana PPO 506.8 percent of total billed charges 348.43 538.48 80% of billed charge AQUAMANTYS BIPOLAR SEALER 6.0 272 RC outpatient 633.5 506.8 Cigna Commercial PPO 348.43 percent of total billed charges 348.43 538.48 55% of Billed Charges AQUAMANTYS BIPOLAR SEALER 6.0 272 RC inpatient 633.5 316.75 IMA of Louisiana Commercial PPO 538.48 percent of total billed charges 316.75 538.48 Inpatient Reimbursement at 85% of Billed Charges AQUAMANTYS BIPOLAR SEALER 6.0 272 RC outpatient 633.5 506.8 IMA of Louisiana Commercial PPO 538.48 percent of total billed charges 348.43 538.48 Reimbursement at 85% of billed charges AQUAMANTYS BIPOLAR SEALER 6.0 272 RC outpatient 633.5 506.8 Aetna Commercial PPO 348.43 percent of total billed charges 348.43 538.48 55 of billed Charges JAMSHIDI NEEDLE - SHS PRODUCT 272 RC inpatient 80.26 40.13 BCBS Louisiana PPO 40.13 percent of total billed charges 40.13 68.22 50% of Eligible Charges JAMSHIDI NEEDLE - SHS PRODUCT 272 RC outpatient 80.26 64.21 BCBS Louisiana PPO 64.21 percent of total billed charges 44.14 68.22 80% of billed charge JAMSHIDI NEEDLE - SHS PRODUCT 272 RC outpatient 80.26 64.21 Cigna Commercial PPO 44.14 percent of total billed charges 44.14 68.22 55% of Billed Charges JAMSHIDI NEEDLE - SHS PRODUCT 272 RC inpatient 80.26 40.13 IMA of Louisiana Commercial PPO 68.22 percent of total billed charges 40.13 68.22 Inpatient Reimbursement at 85% of Billed Charges JAMSHIDI NEEDLE - SHS PRODUCT 272 RC outpatient 80.26 64.21 IMA of Louisiana Commercial PPO 68.22 percent of total billed charges 44.14 68.22 Reimbursement at 85% of billed charges JAMSHIDI NEEDLE - SHS PRODUCT 272 RC outpatient 80.26 64.21 Aetna Commercial PPO 44.14 percent of total billed charges 44.14 68.22 55 of billed Charges DEMAYO LEG WRAP - MAKO 272 RC inpatient 110.25 55.13 BCBS Louisiana PPO 55.13 percent of total billed charges 55.13 93.71 50% of Eligible Charges DEMAYO LEG WRAP - MAKO 272 RC outpatient 110.25 88.2 BCBS Louisiana PPO 88.2 percent of total billed charges 60.64 93.71 80% of billed charge DEMAYO LEG WRAP - MAKO 272 RC outpatient 110.25 88.2 Cigna Commercial PPO 60.64 percent of total billed charges 60.64 93.71 55% of Billed Charges DEMAYO LEG WRAP - MAKO 272 RC inpatient 110.25 55.13 IMA of Louisiana Commercial PPO 93.71 percent of total billed charges 55.13 93.71 Inpatient Reimbursement at 85% of Billed Charges DEMAYO LEG WRAP - MAKO 272 RC outpatient 110.25 88.2 IMA of Louisiana Commercial PPO 93.71 percent of total billed charges 60.64 93.71 Reimbursement at 85% of billed charges DEMAYO LEG WRAP - MAKO 272 RC outpatient 110.25 88.2 Aetna Commercial PPO 60.64 percent of total billed charges 60.64 93.71 55 of billed Charges FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC inpatient 237.51 118.76 BCBS Louisiana PPO 118.76 percent of total billed charges 118.76 201.88 50% of Eligible Charges FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC outpatient 237.51 190.01 BCBS Louisiana PPO 190.01 percent of total billed charges 130.63 201.88 80% of billed charge FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC outpatient 237.51 190.01 Cigna Commercial PPO 130.63 percent of total billed charges 130.63 201.88 55% of Billed Charges FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC inpatient 237.51 118.76 IMA of Louisiana Commercial PPO 201.88 percent of total billed charges 118.76 201.88 Inpatient Reimbursement at 85% of Billed Charges FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC outpatient 237.51 190.01 IMA of Louisiana Commercial PPO 201.88 percent of total billed charges 130.63 201.88 Reimbursement at 85% of billed charges FEMORAL/TIBIAL CHECKPOINT KIT - MAKO 272 RC outpatient 237.51 190.01 Aetna Commercial PPO 130.63 percent of total billed charges 130.63 201.88 55 of billed Charges BONE PIN 4 X 110MM - MAKO 272 RC inpatient 403.2 201.6 BCBS Louisiana PPO 201.6 percent of total billed charges 201.6 342.72 50% of Eligible Charges BONE PIN 4 X 110MM - MAKO 272 RC outpatient 403.2 322.56 BCBS Louisiana PPO 322.56 percent of total billed charges 221.76 342.72 80% of billed charge BONE PIN 4 X 110MM - MAKO 272 RC outpatient 403.2 322.56 Cigna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55% of Billed Charges BONE PIN 4 X 110MM - MAKO 272 RC inpatient 403.2 201.6 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 201.6 342.72 Inpatient Reimbursement at 85% of Billed Charges BONE PIN 4 X 110MM - MAKO 272 RC outpatient 403.2 322.56 IMA of Louisiana Commercial PPO 342.72 percent of total billed charges 221.76 342.72 Reimbursement at 85% of billed charges BONE PIN 4 X 110MM - MAKO 272 RC outpatient 403.2 322.56 Aetna Commercial PPO 221.76 percent of total billed charges 221.76 342.72 55 of billed Charges SAW BLADE MAKO - STANDARD #116170 272 RC inpatient 504.12 252.06 BCBS Louisiana PPO 252.06 percent of total billed charges 252.06 428.5 50% of Eligible Charges SAW BLADE MAKO - STANDARD #116170 272 RC outpatient 504.12 403.3 BCBS Louisiana PPO 403.3 percent of total billed charges 277.27 428.5 80% of billed charge SAW BLADE MAKO - STANDARD #116170 272 RC outpatient 504.12 403.3 Cigna Commercial PPO 277.27 percent of total billed charges 277.27 428.5 55% of Billed Charges SAW BLADE MAKO - STANDARD #116170 272 RC inpatient 504.12 252.06 IMA of Louisiana Commercial PPO 428.5 percent of total billed charges 252.06 428.5 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE MAKO - STANDARD #116170 272 RC outpatient 504.12 403.3 IMA of Louisiana Commercial PPO 428.5 percent of total billed charges 277.27 428.5 Reimbursement at 85% of billed charges SAW BLADE MAKO - STANDARD #116170 272 RC outpatient 504.12 403.3 Aetna Commercial PPO 277.27 percent of total billed charges 277.27 428.5 55 of billed Charges LEG POSITIONER DISP. KIT - MAKO 272 RC inpatient 110.25 55.13 BCBS Louisiana PPO 55.13 percent of total billed charges 55.13 93.71 50% of Eligible Charges LEG POSITIONER DISP. KIT - MAKO 272 RC outpatient 110.25 88.2 BCBS Louisiana PPO 88.2 percent of total billed charges 60.64 93.71 80% of billed charge LEG POSITIONER DISP. KIT - MAKO 272 RC outpatient 110.25 88.2 Cigna Commercial PPO 60.64 percent of total billed charges 60.64 93.71 55% of Billed Charges LEG POSITIONER DISP. KIT - MAKO 272 RC inpatient 110.25 55.13 IMA of Louisiana Commercial PPO 93.71 percent of total billed charges 55.13 93.71 Inpatient Reimbursement at 85% of Billed Charges LEG POSITIONER DISP. KIT - MAKO 272 RC outpatient 110.25 88.2 IMA of Louisiana Commercial PPO 93.71 percent of total billed charges 60.64 93.71 Reimbursement at 85% of billed charges LEG POSITIONER DISP. KIT - MAKO 272 RC outpatient 110.25 88.2 Aetna Commercial PPO 60.64 percent of total billed charges 60.64 93.71 55 of billed Charges FINGER SPLINT CLOCK SPRING - MED 270 RC inpatient 69.44 34.72 BCBS Louisiana PPO 34.72 percent of total billed charges 34.72 59.02 50% of Eligible Charges FINGER SPLINT CLOCK SPRING - MED 270 RC outpatient 69.44 55.55 BCBS Louisiana PPO 55.55 percent of total billed charges 38.19 59.02 80% of billed charge FINGER SPLINT CLOCK SPRING - MED 270 RC outpatient 69.44 55.55 Cigna Commercial PPO 38.19 percent of total billed charges 38.19 59.02 55% of Billed Charges FINGER SPLINT CLOCK SPRING - MED 270 RC inpatient 69.44 34.72 IMA of Louisiana Commercial PPO 59.02 percent of total billed charges 34.72 59.02 Inpatient Reimbursement at 85% of Billed Charges FINGER SPLINT CLOCK SPRING - MED 270 RC outpatient 69.44 55.55 IMA of Louisiana Commercial PPO 59.02 percent of total billed charges 38.19 59.02 Reimbursement at 85% of billed charges FINGER SPLINT CLOCK SPRING - MED 270 RC outpatient 69.44 55.55 Aetna Commercial PPO 38.19 percent of total billed charges 38.19 59.02 55 of billed Charges MIAMI J COLLAR XSMALL 270 RC inpatient 341.81 170.91 BCBS Louisiana PPO 170.91 percent of total billed charges 170.91 290.54 50% of Eligible Charges MIAMI J COLLAR XSMALL 270 RC outpatient 341.81 273.45 BCBS Louisiana PPO 273.45 percent of total billed charges 188 290.54 80% of billed charge MIAMI J COLLAR XSMALL 270 RC outpatient 341.81 273.45 Cigna Commercial PPO 188 percent of total billed charges 188 290.54 55% of Billed Charges MIAMI J COLLAR XSMALL 270 RC inpatient 341.81 170.91 IMA of Louisiana Commercial PPO 290.54 percent of total billed charges 170.91 290.54 Inpatient Reimbursement at 85% of Billed Charges MIAMI J COLLAR XSMALL 270 RC outpatient 341.81 273.45 IMA of Louisiana Commercial PPO 290.54 percent of total billed charges 188 290.54 Reimbursement at 85% of billed charges MIAMI J COLLAR XSMALL 270 RC outpatient 341.81 273.45 Aetna Commercial PPO 188 percent of total billed charges 188 290.54 55 of billed Charges "PANTY, MESH ONE SIZE" 270 RC inpatient 4.08 2.04 BCBS Louisiana PPO 2.04 percent of total billed charges 2.04 3.47 50% of Eligible Charges "PANTY, MESH ONE SIZE" 270 RC outpatient 4.08 3.26 BCBS Louisiana PPO 3.26 percent of total billed charges 2.24 3.47 80% of billed charge "PANTY, MESH ONE SIZE" 270 RC outpatient 4.08 3.26 Cigna Commercial PPO 2.24 percent of total billed charges 2.24 3.47 55% of Billed Charges "PANTY, MESH ONE SIZE" 270 RC inpatient 4.08 2.04 IMA of Louisiana Commercial PPO 3.47 percent of total billed charges 2.04 3.47 Inpatient Reimbursement at 85% of Billed Charges "PANTY, MESH ONE SIZE" 270 RC outpatient 4.08 3.26 IMA of Louisiana Commercial PPO 3.47 percent of total billed charges 2.24 3.47 Reimbursement at 85% of billed charges "PANTY, MESH ONE SIZE" 270 RC outpatient 4.08 3.26 Aetna Commercial PPO 2.24 percent of total billed charges 2.24 3.47 55 of billed Charges PORT ACCESS KIT 272 RC inpatient 67.4 33.7 BCBS Louisiana PPO 33.7 percent of total billed charges 33.7 57.29 50% of Eligible Charges PORT ACCESS KIT 272 RC outpatient 67.4 53.92 BCBS Louisiana PPO 53.92 percent of total billed charges 37.07 57.29 80% of billed charge PORT ACCESS KIT 272 RC outpatient 67.4 53.92 Cigna Commercial PPO 37.07 percent of total billed charges 37.07 57.29 55% of Billed Charges PORT ACCESS KIT 272 RC inpatient 67.4 33.7 IMA of Louisiana Commercial PPO 57.29 percent of total billed charges 33.7 57.29 Inpatient Reimbursement at 85% of Billed Charges PORT ACCESS KIT 272 RC outpatient 67.4 53.92 IMA of Louisiana Commercial PPO 57.29 percent of total billed charges 37.07 57.29 Reimbursement at 85% of billed charges PORT ACCESS KIT 272 RC outpatient 67.4 53.92 Aetna Commercial PPO 37.07 percent of total billed charges 37.07 57.29 55 of billed Charges EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC inpatient 560 280 BCBS Louisiana PPO 280 percent of total billed charges 280 476 50% of Eligible Charges EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC outpatient 560 448 BCBS Louisiana PPO 448 percent of total billed charges 308 476 80% of billed charge EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC outpatient 560 448 Cigna Commercial PPO 308 percent of total billed charges 308 476 55% of Billed Charges EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC inpatient 560 280 IMA of Louisiana Commercial PPO 476 percent of total billed charges 280 476 Inpatient Reimbursement at 85% of Billed Charges EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC outpatient 560 448 IMA of Louisiana Commercial PPO 476 percent of total billed charges 308 476 Reimbursement at 85% of billed charges EXTRACTOR STRIPPED SCREW 04MM CANNULATED 272 RC outpatient 560 448 Aetna Commercial PPO 308 percent of total billed charges 308 476 55 of billed Charges FOOT PEDAL COVER 272 RC inpatient 591.56 295.78 BCBS Louisiana PPO 295.78 percent of total billed charges 295.78 502.83 50% of Eligible Charges FOOT PEDAL COVER 272 RC outpatient 591.56 473.25 BCBS Louisiana PPO 473.25 percent of total billed charges 325.36 502.83 80% of billed charge FOOT PEDAL COVER 272 RC outpatient 591.56 473.25 Cigna Commercial PPO 325.36 percent of total billed charges 325.36 502.83 55% of Billed Charges FOOT PEDAL COVER 272 RC inpatient 591.56 295.78 IMA of Louisiana Commercial PPO 502.83 percent of total billed charges 295.78 502.83 Inpatient Reimbursement at 85% of Billed Charges FOOT PEDAL COVER 272 RC outpatient 591.56 473.25 IMA of Louisiana Commercial PPO 502.83 percent of total billed charges 325.36 502.83 Reimbursement at 85% of billed charges FOOT PEDAL COVER 272 RC outpatient 591.56 473.25 Aetna Commercial PPO 325.36 percent of total billed charges 325.36 502.83 55 of billed Charges ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC inpatient 540 270 BCBS Louisiana PPO 270 percent of total billed charges 270 459 50% of Eligible Charges ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC outpatient 540 432 BCBS Louisiana PPO 432 percent of total billed charges 297 459 80% of billed charge ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC outpatient 540 432 Cigna Commercial PPO 297 percent of total billed charges 297 459 55% of Billed Charges ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC inpatient 540 270 IMA of Louisiana Commercial PPO 459 percent of total billed charges 270 459 Inpatient Reimbursement at 85% of Billed Charges ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC outpatient 540 432 IMA of Louisiana Commercial PPO 459 percent of total billed charges 297 459 Reimbursement at 85% of billed charges ABRADER 2.9MM MAG- MINI - S&N ENDO 272 RC outpatient 540 432 Aetna Commercial PPO 297 percent of total billed charges 297 459 55 of billed Charges CATHETER FOLEY COUDE 16FR 5CC 272 RC inpatient 129.64 64.82 BCBS Louisiana PPO 64.82 percent of total billed charges 64.82 110.19 50% of Eligible Charges CATHETER FOLEY COUDE 16FR 5CC 272 RC outpatient 129.64 103.71 BCBS Louisiana PPO 103.71 percent of total billed charges 71.3 110.19 80% of billed charge CATHETER FOLEY COUDE 16FR 5CC 272 RC outpatient 129.64 103.71 Cigna Commercial PPO 71.3 percent of total billed charges 71.3 110.19 55% of Billed Charges CATHETER FOLEY COUDE 16FR 5CC 272 RC inpatient 129.64 64.82 IMA of Louisiana Commercial PPO 110.19 percent of total billed charges 64.82 110.19 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY COUDE 16FR 5CC 272 RC outpatient 129.64 103.71 IMA of Louisiana Commercial PPO 110.19 percent of total billed charges 71.3 110.19 Reimbursement at 85% of billed charges CATHETER FOLEY COUDE 16FR 5CC 272 RC outpatient 129.64 103.71 Aetna Commercial PPO 71.3 percent of total billed charges 71.3 110.19 55 of billed Charges CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC inpatient 482.55 241.28 BCBS Louisiana PPO 241.28 percent of total billed charges 241.28 410.17 50% of Eligible Charges CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC outpatient 482.55 386.04 BCBS Louisiana PPO 386.04 percent of total billed charges 265.4 410.17 80% of billed charge CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC outpatient 482.55 386.04 Cigna Commercial PPO 265.4 percent of total billed charges 265.4 410.17 55% of Billed Charges CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC inpatient 482.55 241.28 IMA of Louisiana Commercial PPO 410.17 percent of total billed charges 241.28 410.17 Inpatient Reimbursement at 85% of Billed Charges CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC outpatient 482.55 386.04 IMA of Louisiana Commercial PPO 410.17 percent of total billed charges 265.4 410.17 Reimbursement at 85% of billed charges CATHETER FOLEY COUDE LF SILICONE 14FR 5C 272 RC outpatient 482.55 386.04 Aetna Commercial PPO 265.4 percent of total billed charges 265.4 410.17 55 of billed Charges SUTURE GORTEX CV-6 #6J02A 272 RC inpatient 570.57 285.29 BCBS Louisiana PPO 285.29 percent of total billed charges 285.29 484.98 50% of Eligible Charges SUTURE GORTEX CV-6 #6J02A 272 RC outpatient 570.57 456.46 BCBS Louisiana PPO 456.46 percent of total billed charges 313.81 484.98 80% of billed charge SUTURE GORTEX CV-6 #6J02A 272 RC outpatient 570.57 456.46 Cigna Commercial PPO 313.81 percent of total billed charges 313.81 484.98 55% of Billed Charges SUTURE GORTEX CV-6 #6J02A 272 RC inpatient 570.57 285.29 IMA of Louisiana Commercial PPO 484.98 percent of total billed charges 285.29 484.98 Inpatient Reimbursement at 85% of Billed Charges SUTURE GORTEX CV-6 #6J02A 272 RC outpatient 570.57 456.46 IMA of Louisiana Commercial PPO 484.98 percent of total billed charges 313.81 484.98 Reimbursement at 85% of billed charges SUTURE GORTEX CV-6 #6J02A 272 RC outpatient 570.57 456.46 Aetna Commercial PPO 313.81 percent of total billed charges 313.81 484.98 55 of billed Charges PILLOW 20 X26 BED PILLOW 270 RC inpatient 28.52 14.26 BCBS Louisiana PPO 14.26 percent of total billed charges 14.26 24.24 50% of Eligible Charges PILLOW 20 X26 BED PILLOW 270 RC outpatient 28.52 22.82 BCBS Louisiana PPO 22.82 percent of total billed charges 15.69 24.24 80% of billed charge PILLOW 20 X26 BED PILLOW 270 RC outpatient 28.52 22.82 Cigna Commercial PPO 15.69 percent of total billed charges 15.69 24.24 55% of Billed Charges PILLOW 20 X26 BED PILLOW 270 RC inpatient 28.52 14.26 IMA of Louisiana Commercial PPO 24.24 percent of total billed charges 14.26 24.24 Inpatient Reimbursement at 85% of Billed Charges PILLOW 20 X26 BED PILLOW 270 RC outpatient 28.52 22.82 IMA of Louisiana Commercial PPO 24.24 percent of total billed charges 15.69 24.24 Reimbursement at 85% of billed charges PILLOW 20 X26 BED PILLOW 270 RC outpatient 28.52 22.82 Aetna Commercial PPO 15.69 percent of total billed charges 15.69 24.24 55 of billed Charges MULTIFIRE SCORPION NEEDLE 272 RC inpatient 1100 550 BCBS Louisiana PPO 550 percent of total billed charges 550 935 50% of Eligible Charges MULTIFIRE SCORPION NEEDLE 272 RC outpatient 1100 880 BCBS Louisiana PPO 880 percent of total billed charges 605 935 80% of billed charge MULTIFIRE SCORPION NEEDLE 272 RC outpatient 1100 880 Cigna Commercial PPO 605 percent of total billed charges 605 935 55% of Billed Charges MULTIFIRE SCORPION NEEDLE 272 RC inpatient 1100 550 IMA of Louisiana Commercial PPO 935 percent of total billed charges 550 935 Inpatient Reimbursement at 85% of Billed Charges MULTIFIRE SCORPION NEEDLE 272 RC outpatient 1100 880 IMA of Louisiana Commercial PPO 935 percent of total billed charges 605 935 Reimbursement at 85% of billed charges MULTIFIRE SCORPION NEEDLE 272 RC outpatient 1100 880 Aetna Commercial PPO 605 percent of total billed charges 605 935 55 of billed Charges VICRYL 3-0 SH #J864D 272 RC inpatient 48.72 24.36 BCBS Louisiana PPO 24.36 percent of total billed charges 24.36 41.41 50% of Eligible Charges VICRYL 3-0 SH #J864D 272 RC outpatient 48.72 38.98 BCBS Louisiana PPO 38.98 percent of total billed charges 26.8 41.41 80% of billed charge VICRYL 3-0 SH #J864D 272 RC outpatient 48.72 38.98 Cigna Commercial PPO 26.8 percent of total billed charges 26.8 41.41 55% of Billed Charges VICRYL 3-0 SH #J864D 272 RC inpatient 48.72 24.36 IMA of Louisiana Commercial PPO 41.41 percent of total billed charges 24.36 41.41 Inpatient Reimbursement at 85% of Billed Charges VICRYL 3-0 SH #J864D 272 RC outpatient 48.72 38.98 IMA of Louisiana Commercial PPO 41.41 percent of total billed charges 26.8 41.41 Reimbursement at 85% of billed charges VICRYL 3-0 SH #J864D 272 RC outpatient 48.72 38.98 Aetna Commercial PPO 26.8 percent of total billed charges 26.8 41.41 55 of billed Charges CASSETTE ULTA VERALINK - KCI 272 RC inpatient 549.88 274.94 BCBS Louisiana PPO 274.94 percent of total billed charges 274.94 467.4 50% of Eligible Charges CASSETTE ULTA VERALINK - KCI 272 RC outpatient 549.88 439.9 BCBS Louisiana PPO 439.9 percent of total billed charges 302.43 467.4 80% of billed charge CASSETTE ULTA VERALINK - KCI 272 RC outpatient 549.88 439.9 Cigna Commercial PPO 302.43 percent of total billed charges 302.43 467.4 55% of Billed Charges CASSETTE ULTA VERALINK - KCI 272 RC inpatient 549.88 274.94 IMA of Louisiana Commercial PPO 467.4 percent of total billed charges 274.94 467.4 Inpatient Reimbursement at 85% of Billed Charges CASSETTE ULTA VERALINK - KCI 272 RC outpatient 549.88 439.9 IMA of Louisiana Commercial PPO 467.4 percent of total billed charges 302.43 467.4 Reimbursement at 85% of billed charges CASSETTE ULTA VERALINK - KCI 272 RC outpatient 549.88 439.9 Aetna Commercial PPO 302.43 percent of total billed charges 302.43 467.4 55 of billed Charges ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC inpatient 847.5 423.75 BCBS Louisiana PPO 423.75 percent of total billed charges 423.75 720.38 50% of Eligible Charges ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC outpatient 847.5 678 BCBS Louisiana PPO 678 percent of total billed charges 466.13 720.38 80% of billed charge ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC outpatient 847.5 678 Cigna Commercial PPO 466.13 percent of total billed charges 466.13 720.38 55% of Billed Charges ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC inpatient 847.5 423.75 IMA of Louisiana Commercial PPO 720.38 percent of total billed charges 423.75 720.38 Inpatient Reimbursement at 85% of Billed Charges ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC outpatient 847.5 678 IMA of Louisiana Commercial PPO 720.38 percent of total billed charges 466.13 720.38 Reimbursement at 85% of billed charges ZIPLINE 24 CLOSURE DEVICE - ATCH KNEE 272 RC outpatient 847.5 678 Aetna Commercial PPO 466.13 percent of total billed charges 466.13 720.38 55 of billed Charges CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC inpatient 12787.5 6393.75 BCBS Louisiana PPO 6393.75 percent of total billed charges 6393.75 10869.38 50% of Eligible Charges CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC outpatient 12787.5 10230 BCBS Louisiana PPO 10230 percent of total billed charges 4731.38 10869.38 80% of billed charge CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC outpatient 12787.5 10230 Cigna Commercial PPO 7416.75 percent of total billed charges 4731.38 10869.38 58% of Billed Charges/$500 Threshold CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC inpatient 12787.5 6393.75 IMA of Louisiana Commercial PPO 10869.38 percent of total billed charges 6393.75 10869.38 Inpatient Reimbursement at 85% of Billed Charges CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC outpatient 12787.5 10230 IMA of Louisiana Commercial PPO 10869.38 percent of total billed charges 4731.38 10869.38 Reimbursement at 85% of billed charges CARTIMAX VIABLE CARTILAGE ALLOGRAFT C1713 HCPCS 278 RC outpatient 12787.5 10230 Aetna Commercial PPO 4731.38 percent of total billed charges 4731.38 10869.38 37% Of Billed Charges 2000 HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC inpatient 417.62 208.81 BCBS Louisiana PPO 208.81 percent of total billed charges 208.81 354.98 50% of Eligible Charges HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC outpatient 417.62 334.1 BCBS Louisiana PPO 334.1 percent of total billed charges 229.69 354.98 80% of billed charge HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC outpatient 417.62 334.1 Cigna Commercial PPO 229.69 percent of total billed charges 229.69 354.98 55% of Billed Charges HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC inpatient 417.62 208.81 IMA of Louisiana Commercial PPO 354.98 percent of total billed charges 208.81 354.98 Inpatient Reimbursement at 85% of Billed Charges HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC outpatient 417.62 334.1 IMA of Louisiana Commercial PPO 354.98 percent of total billed charges 229.69 354.98 Reimbursement at 85% of billed charges HEMOPOINT H2 NXT MICROCUVETTE TEST 272 RC outpatient 417.62 334.1 Aetna Commercial PPO 229.69 percent of total billed charges 229.69 354.98 55 of billed Charges OR SERVICES LEVEL 2 360 RC inpatient 1000 500 BCBS Louisiana PPO 500 percent of total billed charges 500 850 50% of Eligible Charges OR SERVICES LEVEL 2 360 RC outpatient 1000 800 BCBS Louisiana PPO 800 percent of total billed charges 550 850 80% of billed charge OR SERVICES LEVEL 2 360 RC outpatient 1000 800 Cigna Commercial PPO 550 percent of total billed charges 550 850 55% of Billed Charges OR SERVICES LEVEL 2 360 RC inpatient 1000 500 IMA of Louisiana Commercial PPO 850 percent of total billed charges 500 850 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 2 360 RC outpatient 1000 800 IMA of Louisiana Commercial PPO 850 percent of total billed charges 550 850 Reimbursement at 85% of billed charges OR SERVICES LEVEL 2 360 RC outpatient 1000 800 Aetna Commercial PPO 550 percent of total billed charges 550 850 55 of billed Charges PROC ROOM SERVICES 05 360 RC inpatient 1373 686.5 BCBS Louisiana PPO 686.5 percent of total billed charges 686.5 1167.05 50% of Eligible Charges PROC ROOM SERVICES 05 360 RC outpatient 1373 1098.4 BCBS Louisiana PPO 1098.4 percent of total billed charges 755.15 1167.05 80% of billed charge PROC ROOM SERVICES 05 360 RC outpatient 1373 1098.4 Cigna Commercial PPO 755.15 percent of total billed charges 755.15 1167.05 55% of Billed Charges PROC ROOM SERVICES 05 360 RC inpatient 1373 686.5 IMA of Louisiana Commercial PPO 1167.05 percent of total billed charges 686.5 1167.05 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 05 360 RC outpatient 1373 1098.4 IMA of Louisiana Commercial PPO 1167.05 percent of total billed charges 755.15 1167.05 Reimbursement at 85% of billed charges PROC ROOM SERVICES 05 360 RC outpatient 1373 1098.4 Aetna Commercial PPO 755.15 percent of total billed charges 755.15 1167.05 55 of billed Charges PROC ROOM SERVICES 17 360 RC inpatient 3142 1571 BCBS Louisiana PPO 1571 percent of total billed charges 1571 2670.7 50% of Eligible Charges PROC ROOM SERVICES 17 360 RC outpatient 3142 2513.6 BCBS Louisiana PPO 2513.6 percent of total billed charges 1728.1 2670.7 80% of billed charge PROC ROOM SERVICES 17 360 RC outpatient 3142 2513.6 Cigna Commercial PPO 1728.1 percent of total billed charges 1728.1 2670.7 55% of Billed Charges PROC ROOM SERVICES 17 360 RC inpatient 3142 1571 IMA of Louisiana Commercial PPO 2670.7 percent of total billed charges 1571 2670.7 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 17 360 RC outpatient 3142 2513.6 IMA of Louisiana Commercial PPO 2670.7 percent of total billed charges 1728.1 2670.7 Reimbursement at 85% of billed charges PROC ROOM SERVICES 17 360 RC outpatient 3142 2513.6 Aetna Commercial PPO 1728.1 percent of total billed charges 1728.1 2670.7 55 of billed Charges PROC ROOM SERVICES 19 360 RC inpatient 3295 1647.5 BCBS Louisiana PPO 1647.5 percent of total billed charges 1647.5 2800.75 50% of Eligible Charges PROC ROOM SERVICES 19 360 RC outpatient 3295 2636 BCBS Louisiana PPO 2636 percent of total billed charges 1812.25 2800.75 80% of billed charge PROC ROOM SERVICES 19 360 RC outpatient 3295 2636 Cigna Commercial PPO 1812.25 percent of total billed charges 1812.25 2800.75 55% of Billed Charges PROC ROOM SERVICES 19 360 RC inpatient 3295 1647.5 IMA of Louisiana Commercial PPO 2800.75 percent of total billed charges 1647.5 2800.75 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 19 360 RC outpatient 3295 2636 IMA of Louisiana Commercial PPO 2800.75 percent of total billed charges 1812.25 2800.75 Reimbursement at 85% of billed charges PROC ROOM SERVICES 19 360 RC outpatient 3295 2636 Aetna Commercial PPO 1812.25 percent of total billed charges 1812.25 2800.75 55 of billed Charges PROC ROOM SERVICES 22 360 RC inpatient 3687 1843.5 BCBS Louisiana PPO 1843.5 percent of total billed charges 1843.5 3133.95 50% of Eligible Charges PROC ROOM SERVICES 22 360 RC outpatient 3687 2949.6 BCBS Louisiana PPO 2949.6 percent of total billed charges 2027.85 3133.95 80% of billed charge PROC ROOM SERVICES 22 360 RC outpatient 3687 2949.6 Cigna Commercial PPO 2027.85 percent of total billed charges 2027.85 3133.95 55% of Billed Charges PROC ROOM SERVICES 22 360 RC inpatient 3687 1843.5 IMA of Louisiana Commercial PPO 3133.95 percent of total billed charges 1843.5 3133.95 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 22 360 RC outpatient 3687 2949.6 IMA of Louisiana Commercial PPO 3133.95 percent of total billed charges 2027.85 3133.95 Reimbursement at 85% of billed charges PROC ROOM SERVICES 22 360 RC outpatient 3687 2949.6 Aetna Commercial PPO 2027.85 percent of total billed charges 2027.85 3133.95 55 of billed Charges REC RM 2.0 HR 710 RC inpatient 2100 1050 BCBS Louisiana PPO 1050 percent of total billed charges 1050 1785 50% of Eligible Charges REC RM 2.0 HR 710 RC outpatient 2100 1680 BCBS Louisiana PPO 1680 percent of total billed charges 1155 1785 80% of billed charge REC RM 2.0 HR 710 RC outpatient 2100 1680 Cigna Commercial PPO 1155 percent of total billed charges 1155 1785 55% of Billed Charges REC RM 2.0 HR 710 RC inpatient 2100 1050 IMA of Louisiana Commercial PPO 1785 percent of total billed charges 1050 1785 Inpatient Reimbursement at 85% of Billed Charges REC RM 2.0 HR 710 RC outpatient 2100 1680 IMA of Louisiana Commercial PPO 1785 percent of total billed charges 1155 1785 Reimbursement at 85% of billed charges REC RM 2.0 HR 710 RC outpatient 2100 1680 Aetna Commercial PPO 1155 percent of total billed charges 1155 1785 55 of billed Charges REC RM 2.5 HR 710 RC inpatient 2625 1312.5 BCBS Louisiana PPO 1312.5 percent of total billed charges 1312.5 2231.25 50% of Eligible Charges REC RM 2.5 HR 710 RC outpatient 2625 2100 BCBS Louisiana PPO 2100 percent of total billed charges 1443.75 2231.25 80% of billed charge REC RM 2.5 HR 710 RC outpatient 2625 2100 Cigna Commercial PPO 1443.75 percent of total billed charges 1443.75 2231.25 55% of Billed Charges REC RM 2.5 HR 710 RC inpatient 2625 1312.5 IMA of Louisiana Commercial PPO 2231.25 percent of total billed charges 1312.5 2231.25 Inpatient Reimbursement at 85% of Billed Charges REC RM 2.5 HR 710 RC outpatient 2625 2100 IMA of Louisiana Commercial PPO 2231.25 percent of total billed charges 1443.75 2231.25 Reimbursement at 85% of billed charges REC RM 2.5 HR 710 RC outpatient 2625 2100 Aetna Commercial PPO 1443.75 percent of total billed charges 1443.75 2231.25 55 of billed Charges REC RM 3.0 HR 710 RC inpatient 3150 1575 BCBS Louisiana PPO 1575 percent of total billed charges 1575 2677.5 50% of Eligible Charges REC RM 3.0 HR 710 RC outpatient 3150 2520 BCBS Louisiana PPO 2520 percent of total billed charges 1732.5 2677.5 80% of billed charge REC RM 3.0 HR 710 RC outpatient 3150 2520 Cigna Commercial PPO 1732.5 percent of total billed charges 1732.5 2677.5 55% of Billed Charges REC RM 3.0 HR 710 RC inpatient 3150 1575 IMA of Louisiana Commercial PPO 2677.5 percent of total billed charges 1575 2677.5 Inpatient Reimbursement at 85% of Billed Charges REC RM 3.0 HR 710 RC outpatient 3150 2520 IMA of Louisiana Commercial PPO 2677.5 percent of total billed charges 1732.5 2677.5 Reimbursement at 85% of billed charges REC RM 3.0 HR 710 RC outpatient 3150 2520 Aetna Commercial PPO 1732.5 percent of total billed charges 1732.5 2677.5 55 of billed Charges AFB CULTURE / SMEAR 87116 CPT 300 RC inpatient 121.44 60.72 BCBS Louisiana PPO 60.72 percent of total billed charges 60.72 103.22 50% of Eligible Charges AFB CULTURE / SMEAR 87116 CPT 300 RC outpatient 121.44 85.01 BCBS Louisiana PPO 85.01 percent of total billed charges 35.3 103.22 70% of billed charges AFB CULTURE / SMEAR 87116 CPT 300 RC outpatient 121.44 85.01 Cigna Commercial PPO 66.79 percent of total billed charges 35.3 103.22 55% of Billed Charges AFB CULTURE / SMEAR 87116 CPT 300 RC inpatient 121.44 60.72 IMA of Louisiana Commercial PPO 103.22 percent of total billed charges 60.72 103.22 Inpatient Reimbursement at 85% of Billed Charges AFB CULTURE / SMEAR 87116 CPT 300 RC outpatient 121.44 85.01 IMA of Louisiana Commercial PPO 103.22 percent of total billed charges 35.3 103.22 Reimbursement at 85% of billed charges AFB CULTURE / SMEAR 87116 CPT 300 RC outpatient 121.44 85.01 Aetna Commercial PPO 35.3 fee schedule 35.3 103.22 200% Of Aetna Market Fee Schedule Hospital Technical Rate AMMONIA - STAT 82140 CPT 300 RC inpatient 44.98 22.49 BCBS Louisiana PPO 22.49 percent of total billed charges 22.49 38.23 50% of Eligible Charges AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 BCBS Louisiana PPO 31.49 percent of total billed charges 24.74 47.64 70% of billed charges AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 Cigna Commercial PPO 24.74 percent of total billed charges 24.74 47.64 55% of Billed Charges AMMONIA - STAT 82140 CPT 300 RC inpatient 44.98 22.49 IMA of Louisiana Commercial PPO 38.23 percent of total billed charges 22.49 38.23 Inpatient Reimbursement at 85% of Billed Charges AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 IMA of Louisiana Commercial PPO 38.23 percent of total billed charges 24.74 47.64 Reimbursement at 85% of billed charges AMMONIA - STAT 82140 CPT 300 RC outpatient 44.98 31.49 Aetna Commercial PPO 47.64 fee schedule 24.74 47.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate CREATININE 82565 CPT 300 RC inpatient 15.83 7.92 BCBS Louisiana PPO 7.92 percent of total billed charges 7.92 13.46 50% of Eligible Charges CREATININE 82565 CPT 300 RC outpatient 15.83 11.08 BCBS Louisiana PPO 11.08 percent of total billed charges 8.71 16.76 70% of billed charges CREATININE 82565 CPT 300 RC outpatient 15.83 11.08 Cigna Commercial PPO 8.71 percent of total billed charges 8.71 16.76 55% of Billed Charges CREATININE 82565 CPT 300 RC inpatient 15.83 7.92 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 7.92 13.46 Inpatient Reimbursement at 85% of Billed Charges CREATININE 82565 CPT 300 RC outpatient 15.83 11.08 IMA of Louisiana Commercial PPO 13.46 percent of total billed charges 8.71 16.76 Reimbursement at 85% of billed charges CREATININE 82565 CPT 300 RC outpatient 15.83 11.08 Aetna Commercial PPO 16.76 fee schedule 8.71 16.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate H&H 85018 CPT 300 RC inpatient 30.88 15.44 BCBS Louisiana PPO 15.44 percent of total billed charges 15.44 26.25 50% of Eligible Charges H&H 85018 CPT 300 RC outpatient 30.88 21.62 BCBS Louisiana PPO 21.62 percent of total billed charges 7.76 26.25 70% of billed charges H&H 85018 CPT 300 RC outpatient 30.88 21.62 Cigna Commercial PPO 16.98 percent of total billed charges 7.76 26.25 55% of Billed Charges H&H 85018 CPT 300 RC inpatient 30.88 15.44 IMA of Louisiana Commercial PPO 26.25 percent of total billed charges 15.44 26.25 Inpatient Reimbursement at 85% of Billed Charges H&H 85018 CPT 300 RC outpatient 30.88 21.62 IMA of Louisiana Commercial PPO 26.25 percent of total billed charges 7.76 26.25 Reimbursement at 85% of billed charges H&H 85018 CPT 300 RC outpatient 30.88 21.62 Aetna Commercial PPO 7.76 fee schedule 7.76 26.25 200% Of Aetna Market Fee Schedule Hospital Technical Rate URINE PREGNANCY TEST 81025 CPT 300 RC inpatient 21.53 10.77 BCBS Louisiana PPO 10.77 percent of total billed charges 10.77 18.3 50% of Eligible Charges URINE PREGNANCY TEST 81025 CPT 300 RC outpatient 21.53 15.07 BCBS Louisiana PPO 15.07 percent of total billed charges 11.84 20.66 70% of billed charges URINE PREGNANCY TEST 81025 CPT 300 RC outpatient 21.53 15.07 Cigna Commercial PPO 11.84 percent of total billed charges 11.84 20.66 55% of Billed Charges URINE PREGNANCY TEST 81025 CPT 300 RC inpatient 21.53 10.77 IMA of Louisiana Commercial PPO 18.3 percent of total billed charges 10.77 18.3 Inpatient Reimbursement at 85% of Billed Charges URINE PREGNANCY TEST 81025 CPT 300 RC outpatient 21.53 15.07 IMA of Louisiana Commercial PPO 18.3 percent of total billed charges 11.84 20.66 Reimbursement at 85% of billed charges URINE PREGNANCY TEST 81025 CPT 300 RC outpatient 21.53 15.07 Aetna Commercial PPO 20.66 fee schedule 11.84 20.66 200% Of Aetna Market Fee Schedule Hospital Technical Rate CROSS MATCH 86900 CPT 300 RC inpatient 9.23 4.62 BCBS Louisiana PPO 4.62 percent of total billed charges 4.62 7.85 50% of Eligible Charges CROSS MATCH 86900 CPT 300 RC outpatient 9.23 6.46 BCBS Louisiana PPO 6.46 percent of total billed charges 5.08 9.76 70% of billed charges CROSS MATCH 86900 CPT 300 RC outpatient 9.23 6.46 Cigna Commercial PPO 5.08 percent of total billed charges 5.08 9.76 55% of Billed Charges CROSS MATCH 86900 CPT 300 RC inpatient 9.23 4.62 IMA of Louisiana Commercial PPO 7.85 percent of total billed charges 4.62 7.85 Inpatient Reimbursement at 85% of Billed Charges CROSS MATCH 86900 CPT 300 RC outpatient 9.23 6.46 IMA of Louisiana Commercial PPO 7.85 percent of total billed charges 5.08 9.76 Reimbursement at 85% of billed charges CROSS MATCH 86900 CPT 300 RC outpatient 9.23 6.46 Aetna Commercial PPO 9.76 fee schedule 5.08 9.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate D DIMER 85379 CPT 300 RC inpatient 31.4 15.7 BCBS Louisiana PPO 15.7 percent of total billed charges 15.7 26.69 50% of Eligible Charges D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 BCBS Louisiana PPO 21.98 percent of total billed charges 17.27 33.28 70% of billed charges D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 Cigna Commercial PPO 17.27 percent of total billed charges 17.27 33.28 55% of Billed Charges D DIMER 85379 CPT 300 RC inpatient 31.4 15.7 IMA of Louisiana Commercial PPO 26.69 percent of total billed charges 15.7 26.69 Inpatient Reimbursement at 85% of Billed Charges D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 IMA of Louisiana Commercial PPO 26.69 percent of total billed charges 17.27 33.28 Reimbursement at 85% of billed charges D DIMER 85379 CPT 300 RC outpatient 31.4 21.98 Aetna Commercial PPO 33.28 fee schedule 17.27 33.28 200% Of Aetna Market Fee Schedule Hospital Technical Rate CPK - CK LEVEL 82550 CPT 300 RC inpatient 20.1 10.05 BCBS Louisiana PPO 10.05 percent of total billed charges 10.05 17.09 50% of Eligible Charges CPK - CK LEVEL 82550 CPT 300 RC outpatient 20.1 14.07 BCBS Louisiana PPO 14.07 percent of total billed charges 11.06 21.28 70% of billed charges CPK - CK LEVEL 82550 CPT 300 RC outpatient 20.1 14.07 Cigna Commercial PPO 11.06 percent of total billed charges 11.06 21.28 55% of Billed Charges CPK - CK LEVEL 82550 CPT 300 RC inpatient 20.1 10.05 IMA of Louisiana Commercial PPO 17.09 percent of total billed charges 10.05 17.09 Inpatient Reimbursement at 85% of Billed Charges CPK - CK LEVEL 82550 CPT 300 RC outpatient 20.1 14.07 IMA of Louisiana Commercial PPO 17.09 percent of total billed charges 11.06 21.28 Reimbursement at 85% of billed charges CPK - CK LEVEL 82550 CPT 300 RC outpatient 20.1 14.07 Aetna Commercial PPO 21.28 fee schedule 11.06 21.28 200% Of Aetna Market Fee Schedule Hospital Technical Rate LD - LDH 83615 CPT 300 RC inpatient 18.63 9.32 BCBS Louisiana PPO 9.32 percent of total billed charges 9.32 15.84 50% of Eligible Charges LD - LDH 83615 CPT 300 RC outpatient 18.63 13.04 BCBS Louisiana PPO 13.04 percent of total billed charges 10.25 19.72 70% of billed charges LD - LDH 83615 CPT 300 RC outpatient 18.63 13.04 Cigna Commercial PPO 10.25 percent of total billed charges 10.25 19.72 55% of Billed Charges LD - LDH 83615 CPT 300 RC inpatient 18.63 9.32 IMA of Louisiana Commercial PPO 15.84 percent of total billed charges 9.32 15.84 Inpatient Reimbursement at 85% of Billed Charges LD - LDH 83615 CPT 300 RC outpatient 18.63 13.04 IMA of Louisiana Commercial PPO 15.84 percent of total billed charges 10.25 19.72 Reimbursement at 85% of billed charges LD - LDH 83615 CPT 300 RC outpatient 18.63 13.04 Aetna Commercial PPO 19.72 fee schedule 10.25 19.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 BCBS Louisiana PPO 6.98 percent of total billed charges 6.98 11.86 50% of Eligible Charges URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 BCBS Louisiana PPO 9.77 percent of total billed charges 7.67 14.78 70% of billed charges URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Cigna Commercial PPO 7.67 percent of total billed charges 7.67 14.78 55% of Billed Charges URIC ACID LEVEL 84550 CPT 300 RC inpatient 13.95 6.98 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 6.98 11.86 Inpatient Reimbursement at 85% of Billed Charges URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 7.67 14.78 Reimbursement at 85% of billed charges URIC ACID LEVEL 84550 CPT 300 RC outpatient 13.95 9.77 Aetna Commercial PPO 14.78 fee schedule 7.67 14.78 200% Of Aetna Market Fee Schedule Hospital Technical Rate LIPID PANEL 80061 CPT 301 RC inpatient 41.33 20.67 BCBS Louisiana PPO 20.67 percent of total billed charges 20.67 35.13 50% of Eligible Charges LIPID PANEL 80061 CPT 301 RC outpatient 41.33 28.93 BCBS Louisiana PPO 28.93 percent of total billed charges 22.73 39.1 70% of billed charges LIPID PANEL 80061 CPT 301 RC outpatient 41.33 28.93 Cigna Commercial PPO 22.73 percent of total billed charges 22.73 39.1 55% of Billed Charges LIPID PANEL 80061 CPT 301 RC inpatient 41.33 20.67 IMA of Louisiana Commercial PPO 35.13 percent of total billed charges 20.67 35.13 Inpatient Reimbursement at 85% of Billed Charges LIPID PANEL 80061 CPT 301 RC outpatient 41.33 28.93 IMA of Louisiana Commercial PPO 35.13 percent of total billed charges 22.73 39.1 Reimbursement at 85% of billed charges LIPID PANEL 80061 CPT 301 RC outpatient 41.33 28.93 Aetna Commercial PPO 39.1 fee schedule 22.73 39.1 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 BCBS Louisiana PPO 11.99 percent of total billed charges 11.99 20.38 50% of Eligible Charges inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 BCBS Louisiana PPO 16.79 percent of total billed charges 13.19 25.42 70% of billed charges inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Cigna Commercial PPO 13.19 percent of total billed charges 13.19 25.42 55% of Billed Charges inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC inpatient 23.98 11.99 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 11.99 20.38 Inpatient Reimbursement at 85% of Billed Charges inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 IMA of Louisiana Commercial PPO 20.38 percent of total billed charges 13.19 25.42 Reimbursement at 85% of billed charges inpt3_CBC W/ AUTO DIFF 85025 CPT 300 RC outpatient 23.98 16.79 Aetna Commercial PPO 25.42 fee schedule 13.19 25.42 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_COMP METABO PANEL 80053 CPT 300 RC inpatient 32.6 16.3 BCBS Louisiana PPO 16.3 percent of total billed charges 16.3 27.71 50% of Eligible Charges inpt3_COMP METABO PANEL 80053 CPT 300 RC outpatient 32.6 22.82 BCBS Louisiana PPO 22.82 percent of total billed charges 17.93 34.54 70% of billed charges inpt3_COMP METABO PANEL 80053 CPT 300 RC outpatient 32.6 22.82 Cigna Commercial PPO 17.93 percent of total billed charges 17.93 34.54 55% of Billed Charges inpt3_COMP METABO PANEL 80053 CPT 300 RC inpatient 32.6 16.3 IMA of Louisiana Commercial PPO 27.71 percent of total billed charges 16.3 27.71 Inpatient Reimbursement at 85% of Billed Charges inpt3_COMP METABO PANEL 80053 CPT 300 RC outpatient 32.6 22.82 IMA of Louisiana Commercial PPO 27.71 percent of total billed charges 17.93 34.54 Reimbursement at 85% of billed charges inpt3_COMP METABO PANEL 80053 CPT 300 RC outpatient 32.6 22.82 Aetna Commercial PPO 34.54 fee schedule 17.93 34.54 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_CULT URINE RTN 87086 CPT 300 RC inpatient 24.9 12.45 BCBS Louisiana PPO 12.45 percent of total billed charges 12.45 21.17 50% of Eligible Charges inpt3_CULT URINE RTN 87086 CPT 300 RC outpatient 24.9 17.43 BCBS Louisiana PPO 17.43 percent of total billed charges 13.7 26.4 70% of billed charges inpt3_CULT URINE RTN 87086 CPT 300 RC outpatient 24.9 17.43 Cigna Commercial PPO 13.7 percent of total billed charges 13.7 26.4 55% of Billed Charges inpt3_CULT URINE RTN 87086 CPT 300 RC inpatient 24.9 12.45 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 12.45 21.17 Inpatient Reimbursement at 85% of Billed Charges inpt3_CULT URINE RTN 87086 CPT 300 RC outpatient 24.9 17.43 IMA of Louisiana Commercial PPO 21.17 percent of total billed charges 13.7 26.4 Reimbursement at 85% of billed charges inpt3_CULT URINE RTN 87086 CPT 300 RC outpatient 24.9 17.43 Aetna Commercial PPO 26.4 fee schedule 13.7 26.4 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_CK LEVEL - CPK 82550 CPT 300 RC inpatient 27.68 13.84 BCBS Louisiana PPO 13.84 percent of total billed charges 13.84 23.53 50% of Eligible Charges inpt3_CK LEVEL - CPK 82550 CPT 300 RC outpatient 27.68 19.38 BCBS Louisiana PPO 19.38 percent of total billed charges 15.22 23.53 70% of billed charges inpt3_CK LEVEL - CPK 82550 CPT 300 RC outpatient 27.68 19.38 Cigna Commercial PPO 15.22 percent of total billed charges 15.22 23.53 55% of Billed Charges inpt3_CK LEVEL - CPK 82550 CPT 300 RC inpatient 27.68 13.84 IMA of Louisiana Commercial PPO 23.53 percent of total billed charges 13.84 23.53 Inpatient Reimbursement at 85% of Billed Charges inpt3_CK LEVEL - CPK 82550 CPT 300 RC outpatient 27.68 19.38 IMA of Louisiana Commercial PPO 23.53 percent of total billed charges 15.22 23.53 Reimbursement at 85% of billed charges inpt3_CK LEVEL - CPK 82550 CPT 300 RC outpatient 27.68 19.38 Aetna Commercial PPO 21.28 fee schedule 15.22 23.53 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_TROPONIN 1 84484 CPT 301 RC inpatient 31.18 15.59 BCBS Louisiana PPO 15.59 percent of total billed charges 15.59 26.5 50% of Eligible Charges inpt3_TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 BCBS Louisiana PPO 21.83 percent of total billed charges 17.15 32.16 70% of billed charges inpt3_TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 Cigna Commercial PPO 17.15 percent of total billed charges 17.15 32.16 55% of Billed Charges inpt3_TROPONIN 1 84484 CPT 301 RC inpatient 31.18 15.59 IMA of Louisiana Commercial PPO 26.5 percent of total billed charges 15.59 26.5 Inpatient Reimbursement at 85% of Billed Charges inpt3_TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 IMA of Louisiana Commercial PPO 26.5 percent of total billed charges 17.15 32.16 Reimbursement at 85% of billed charges inpt3_TROPONIN 1 84484 CPT 301 RC outpatient 31.18 21.83 Aetna Commercial PPO 32.16 fee schedule 17.15 32.16 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_SEDIMENTATION RATE 85652 CPT 300 RC inpatient 11.48 5.74 BCBS Louisiana PPO 5.74 percent of total billed charges 5.74 9.76 50% of Eligible Charges inpt3_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 BCBS Louisiana PPO 8.04 percent of total billed charges 6.31 9.76 70% of billed charges inpt3_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 Cigna Commercial PPO 6.31 percent of total billed charges 6.31 9.76 55% of Billed Charges inpt3_SEDIMENTATION RATE 85652 CPT 300 RC inpatient 11.48 5.74 IMA of Louisiana Commercial PPO 9.76 percent of total billed charges 5.74 9.76 Inpatient Reimbursement at 85% of Billed Charges inpt3_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 IMA of Louisiana Commercial PPO 9.76 percent of total billed charges 6.31 9.76 Reimbursement at 85% of billed charges inpt3_SEDIMENTATION RATE 85652 CPT 300 RC outpatient 11.48 8.04 Aetna Commercial PPO 8.84 fee schedule 6.31 9.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC inpatient 179.58 89.79 BCBS Louisiana PPO 89.79 percent of total billed charges 89.79 152.64 50% of Eligible Charges DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC outpatient 179.58 125.71 BCBS Louisiana PPO 125.71 percent of total billed charges 98.77 191.54 70% of billed charges DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC outpatient 179.58 125.71 Cigna Commercial PPO 98.77 percent of total billed charges 98.77 191.54 55% of Billed Charges DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC inpatient 179.58 89.79 IMA of Louisiana Commercial PPO 152.64 percent of total billed charges 89.79 152.64 Inpatient Reimbursement at 85% of Billed Charges DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC outpatient 179.58 125.71 IMA of Louisiana Commercial PPO 152.64 percent of total billed charges 98.77 191.54 Reimbursement at 85% of billed charges DRUG SCREEN W/O CONFIRM URINE 80307 CPT 301 RC outpatient 179.58 125.71 Aetna Commercial PPO 191.54 fee schedule 98.77 191.54 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 BCBS Louisiana PPO 14.99 percent of total billed charges 14.99 25.48 50% of Eligible Charges prad_HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 BCBS Louisiana PPO 20.99 percent of total billed charges 16.49 31.72 70% of billed charges prad_HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Cigna Commercial PPO 16.49 percent of total billed charges 16.49 31.72 55% of Billed Charges prad_HEMOGLOBIN A1C 83036 CPT 300 RC inpatient 29.98 14.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 14.99 25.48 Inpatient Reimbursement at 85% of Billed Charges prad_HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 IMA of Louisiana Commercial PPO 25.48 percent of total billed charges 16.49 31.72 Reimbursement at 85% of billed charges prad_HEMOGLOBIN A1C 83036 CPT 300 RC outpatient 29.98 20.99 Aetna Commercial PPO 31.72 fee schedule 16.49 31.72 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC inpatient 300 150 BCBS Louisiana PPO 150 percent of total billed charges 150 255 50% of Eligible Charges XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC outpatient 300 210 BCBS Louisiana PPO 210 percent of total billed charges 165 700 70% of billed charges XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC outpatient 300 210 Cigna Commercial PPO 165 percent of total billed charges 165 700 55% of Billed Charges XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC inpatient 300 150 IMA of Louisiana Commercial PPO 255 percent of total billed charges 150 255 Inpatient Reimbursement at 85% of Billed Charges XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC outpatient 300 210 IMA of Louisiana Commercial PPO 255 percent of total billed charges 165 700 Reimbursement at 85% of billed charges XRAY DX CHEST 2 VIEWS 71046 CPT 320 RC outpatient 300 210 Aetna Commercial PPO 700 case rate 165 700 700 Per Code Per DOS Paid In Addition XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT ELBOW AP&LAT 73070 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX FLOUROSCOPY OR 76496 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT FOREARM AP&LA 73090 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX PELVIS AP 72170 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX PELVIS AP 72170 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX PELVIS AP 72170 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX PELVIS AP 72170 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX PELVIS AP 72170 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX PELVIS AP 72170 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT FOREARM AP&LA 73090 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HUMERUS 73060 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT HUMERUS 73060 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT HUMERUS 73060 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT HUMERUS 73060 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HUMERUS 73060 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT HUMERUS 73060 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition C-ARM OR 1-5 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges C-ARM OR 1-5 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 319.43 700 70% of billed charges C-ARM OR 1-5 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Cigna Commercial PPO 319.43 percent of total billed charges 319.43 700 55% of Billed Charges C-ARM OR 1-5 MINUTES 76000 CPT 320 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges C-ARM OR 1-5 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 319.43 700 Reimbursement at 85% of billed charges C-ARM OR 1-5 MINUTES 76000 CPT 320 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 319.43 700 700 Per Code Per DOS Paid In Addition MRI THORACIC SPINE 72146 CPT 612 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI THORACIC SPINE 72146 CPT 612 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI THORACIC SPINE 72146 CPT 612 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI THORACIC SPINE 72146 CPT 612 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI THORACIC SPINE 72146 CPT 612 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI THORACIC SPINE 72146 CPT 612 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC inpatient 145 72.5 BCBS Louisiana PPO 72.5 percent of total billed charges 72.5 123.25 50% of Eligible Charges XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC outpatient 145 101.5 BCBS Louisiana PPO 101.5 percent of total billed charges 79.75 700 70% of billed charges XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC outpatient 145 101.5 Cigna Commercial PPO 79.75 percent of total billed charges 79.75 700 55% of Billed Charges XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC inpatient 145 72.5 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 72.5 123.25 Inpatient Reimbursement at 85% of Billed Charges XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC outpatient 145 101.5 IMA of Louisiana Commercial PPO 123.25 percent of total billed charges 79.75 700 Reimbursement at 85% of billed charges XRAY DX ABDOMEN 2 VIEWS 74019 CPT 320 RC outpatient 145 101.5 Aetna Commercial PPO 700 case rate 79.75 700 700 Per Code Per DOS Paid In Addition CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT SCAN OF THORAX(CHEST) WITH CONTRAST 71260 CPT 350 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 347.52 700 70% of billed charges CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC outpatient 631.85 442.3 Cigna Commercial PPO 347.52 percent of total billed charges 347.52 700 55% of Billed Charges CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 347.52 700 Reimbursement at 85% of billed charges CT ABD & PELV W & W/O CONTRAST 74178 CPT 320 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 347.52 700 700 Per Code Per DOS Paid In Addition CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC inpatient 1 EA 3.82 1.91 BCBS Louisiana PPO 1.91 percent of total billed charges 1.91 3.25 50% of Eligible Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 BCBS Louisiana PPO 3.06 percent of total billed charges 2.1 3.25 80% of billed charge CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 Cigna Commercial PPO 2.1 percent of total billed charges 2.1 3.25 55% of Billed Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC inpatient 1 EA 3.82 1.91 IMA of Louisiana Commercial PPO 3.25 percent of total billed charges 1.91 3.25 Inpatient Reimbursement at 85% of Billed Charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 IMA of Louisiana Commercial PPO 3.25 percent of total billed charges 2.1 3.25 Reimbursement at 85% of billed charges CHEMSTRIP 9 SG 100 250 RC 5092414510 NDC outpatient 1 EA 3.82 3.06 Aetna Commercial PPO 2.1 percent of total billed charges 2.1 3.25 55 of billed Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MULTIVITAMIN TABLET 250 RC 0904053061 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC inpatient 1 EA 962.04 481.02 BCBS Louisiana PPO 481.02 percent of total billed charges 481.02 817.73 50% of Eligible Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 BCBS Louisiana PPO 769.63 percent of total billed charges 529.12 817.73 80% of billed charge GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 Cigna Commercial PPO 529.12 percent of total billed charges 529.12 817.73 55% of Billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC inpatient 1 EA 962.04 481.02 IMA of Louisiana Commercial PPO 817.73 percent of total billed charges 481.02 817.73 Inpatient Reimbursement at 85% of Billed Charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 IMA of Louisiana Commercial PPO 817.73 percent of total billed charges 529.12 817.73 Reimbursement at 85% of billed charges GELFOAM GELATIN POWDER 250 RC 0009043304 NDC outpatient 1 EA 962.04 769.63 Aetna Commercial PPO 529.12 percent of total billed charges 529.12 817.73 55 of billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SORE THROAT LOZENGE 250 RC 0904625549 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC inpatient 1 EA 1.81 0.91 BCBS Louisiana PPO 0.91 percent of total billed charges 0.91 1.54 50% of Eligible Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 BCBS Louisiana PPO 1.45 percent of total billed charges 1 1.54 80% of billed charge LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 Cigna Commercial PPO 1 percent of total billed charges 1 1.54 55% of Billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC inpatient 1 EA 1.81 0.91 IMA of Louisiana Commercial PPO 1.54 percent of total billed charges 0.91 1.54 Inpatient Reimbursement at 85% of Billed Charges LACTOBACILLUS RHAMNOSUS CAP NON-FORM J8499 HCPCS 250 RC 4910040052 NDC outpatient 1 EA 1.81 1.45 IMA of Louisiana Commercial PPO 1.54 percent of total billed charges 1 1.54 Reimbursement at 85% of billed charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC inpatient 1 EA 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC inpatient 1 EA 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LEMON SWAB FLOOR STOCK 250 RC 5192723220 NDC outpatient 1 EA 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC inpatient 30 ML 47.8 23.9 BCBS Louisiana PPO 23.9 percent of total billed charges 23.9 40.63 50% of Eligible Charges MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC outpatient 30 ML 47.8 38.24 BCBS Louisiana PPO 38.24 percent of total billed charges 26.29 40.63 80% of billed charge MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC outpatient 30 ML 47.8 38.24 Cigna Commercial PPO 26.29 percent of total billed charges 26.29 40.63 55% of Billed Charges MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC inpatient 30 ML 47.8 23.9 IMA of Louisiana Commercial PPO 40.63 percent of total billed charges 23.9 40.63 Inpatient Reimbursement at 85% of Billed Charges MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC outpatient 30 ML 47.8 38.24 IMA of Louisiana Commercial PPO 40.63 percent of total billed charges 26.29 40.63 Reimbursement at 85% of billed charges MEPIVACAINE 1.5% INJ : 30ML 260 RC 6332329337 NDC outpatient 30 ML 47.8 38.24 Aetna Commercial PPO 26.29 percent of total billed charges 26.29 40.63 55 of billed Charges BISACODYL 5MG TABLET 250 RC 0904640761 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BISACODYL 5MG TABLET 250 RC 0904640761 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BISACODYL 5MG TABLET 250 RC 0904640761 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BISACODYL 5MG TABLET 250 RC 0904640761 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BISACODYL 5MG TABLET 250 RC 0904640761 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BISACODYL 5MG TABLET 250 RC 0904640761 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC inpatient 50 ME 16.88 8.44 BCBS Louisiana PPO 8.44 percent of total billed charges 8.44 14.35 50% of Eligible Charges EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC outpatient 50 ME 16.88 13.5 BCBS Louisiana PPO 13.5 percent of total billed charges 9.28 14.35 80% of billed charge EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC outpatient 50 ME 16.88 13.5 Cigna Commercial PPO 9.28 percent of total billed charges 9.28 14.35 55% of Billed Charges EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC inpatient 50 ME 16.88 8.44 IMA of Louisiana Commercial PPO 14.35 percent of total billed charges 8.44 14.35 Inpatient Reimbursement at 85% of Billed Charges EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC outpatient 50 ME 16.88 13.5 IMA of Louisiana Commercial PPO 14.35 percent of total billed charges 9.28 14.35 Reimbursement at 85% of billed charges EPHEDRINE SULF INJ : 50MG/ML 1ML 260 RC 4202321683 NDC outpatient 50 ME 16.88 13.5 Aetna Commercial PPO 9.28 percent of total billed charges 9.28 14.35 55 of billed Charges FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC inpatient 325 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC outpatient 325 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC outpatient 325 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC inpatient 325 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC outpatient 325 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FERROUS SULFATE 325MG TABLET 250 RC 0904759161 NDC outpatient 325 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC inpatient 1000 ML 10.39 5.2 BCBS Louisiana PPO 5.2 percent of total billed charges 5.2 8.83 50% of Eligible Charges SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC outpatient 1000 ML 10.39 8.31 BCBS Louisiana PPO 8.31 percent of total billed charges 5.71 8.83 80% of billed charge SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC outpatient 1000 ML 10.39 8.31 Cigna Commercial PPO 5.71 percent of total billed charges 5.71 8.83 55% of Billed Charges SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC inpatient 1000 ML 10.39 5.2 IMA of Louisiana Commercial PPO 8.83 percent of total billed charges 5.2 8.83 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC outpatient 1000 ML 10.39 8.31 IMA of Louisiana Commercial PPO 8.83 percent of total billed charges 5.71 8.83 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 1000ML 260 RC 0264780000 NDC outpatient 1000 ML 10.39 8.31 Aetna Commercial PPO 5.71 percent of total billed charges 5.71 8.83 55 of billed Charges TRIAMCINOLONE INJ 40MG/ML 1ML J3301 HCPCS 250 RC 7012116571 NDC inpatient 40 ME 53.91 26.96 BCBS Louisiana PPO 26.96 percent of total billed charges 26.96 45.82 50% of Eligible Charges TRIAMCINOLONE INJ 40MG/ML 1ML J3301 HCPCS 250 RC 7012116571 NDC outpatient 40 ME 53.91 43.13 BCBS Louisiana PPO 43.13 percent of total billed charges 29.65 45.82 80% of billed charge TRIAMCINOLONE INJ 40MG/ML 1ML J3301 HCPCS 250 RC 7012116571 NDC outpatient 40 ME 53.91 43.13 Cigna Commercial PPO 29.65 percent of total billed charges 29.65 45.82 55% of Billed Charges TRIAMCINOLONE INJ 40MG/ML 1ML J3301 HCPCS 250 RC 7012116571 NDC inpatient 40 ME 53.91 26.96 IMA of Louisiana Commercial PPO 45.82 percent of total billed charges 26.96 45.82 Inpatient Reimbursement at 85% of Billed Charges TRIAMCINOLONE INJ 40MG/ML 1ML J3301 HCPCS 250 RC 7012116571 NDC outpatient 40 ME 53.91 43.13 IMA of Louisiana Commercial PPO 45.82 percent of total billed charges 29.65 45.82 Reimbursement at 85% of billed charges BUPIVACAINE 0.25% 30ML J3490 HCPCS 250 RC 0409174630 NDC inpatient 30 ML 11.58 5.79 BCBS Louisiana PPO 5.79 percent of total billed charges 5.79 9.84 50% of Eligible Charges BUPIVACAINE 0.25% 30ML J3490 HCPCS 250 RC 0409174630 NDC outpatient 30 ML 11.58 9.26 BCBS Louisiana PPO 9.26 percent of total billed charges 6.37 9.84 80% of billed charge BUPIVACAINE 0.25% 30ML J3490 HCPCS 250 RC 0409174630 NDC outpatient 30 ML 11.58 9.26 Cigna Commercial PPO 6.37 percent of total billed charges 6.37 9.84 55% of Billed Charges BUPIVACAINE 0.25% 30ML J3490 HCPCS 250 RC 0409174630 NDC inpatient 30 ML 11.58 5.79 IMA of Louisiana Commercial PPO 9.84 percent of total billed charges 5.79 9.84 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.25% 30ML J3490 HCPCS 250 RC 0409174630 NDC outpatient 30 ML 11.58 9.26 IMA of Louisiana Commercial PPO 9.84 percent of total billed charges 6.37 9.84 Reimbursement at 85% of billed charges PHENYLEPHRINE 1% 10MG/ML 1ML VIAL J2370 HCPCS 250 RC 0641622925 NDC inpatient 1 ML 3.54 1.77 BCBS Louisiana PPO 1.77 percent of total billed charges 1.77 3.01 50% of Eligible Charges PHENYLEPHRINE 1% 10MG/ML 1ML VIAL J2370 HCPCS 250 RC 0641622925 NDC outpatient 1 ML 3.54 2.83 BCBS Louisiana PPO 2.83 percent of total billed charges 1.95 3.01 80% of billed charge PHENYLEPHRINE 1% 10MG/ML 1ML VIAL J2370 HCPCS 250 RC 0641622925 NDC outpatient 1 ML 3.54 2.83 Cigna Commercial PPO 1.95 percent of total billed charges 1.95 3.01 55% of Billed Charges PHENYLEPHRINE 1% 10MG/ML 1ML VIAL J2370 HCPCS 250 RC 0641622925 NDC inpatient 1 ML 3.54 1.77 IMA of Louisiana Commercial PPO 3.01 percent of total billed charges 1.77 3.01 Inpatient Reimbursement at 85% of Billed Charges PHENYLEPHRINE 1% 10MG/ML 1ML VIAL J2370 HCPCS 250 RC 0641622925 NDC outpatient 1 ML 3.54 2.83 IMA of Louisiana Commercial PPO 3.01 percent of total billed charges 1.95 3.01 Reimbursement at 85% of billed charges OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC inpatient 325 ME 2.14 1.07 BCBS Louisiana PPO 1.07 percent of total billed charges 1.07 1.82 50% of Eligible Charges OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC outpatient 325 ME 2.14 1.71 BCBS Louisiana PPO 1.71 percent of total billed charges 1.18 1.82 80% of billed charge OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC outpatient 325 ME 2.14 1.71 Cigna Commercial PPO 1.18 percent of total billed charges 1.18 1.82 55% of Billed Charges OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC inpatient 325 ME 2.14 1.07 IMA of Louisiana Commercial PPO 1.82 percent of total billed charges 1.07 1.82 Inpatient Reimbursement at 85% of Billed Charges OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC outpatient 325 ME 2.14 1.71 IMA of Louisiana Commercial PPO 1.82 percent of total billed charges 1.18 1.82 Reimbursement at 85% of billed charges OXYCODONE/ACETAMINOPHEN 5/325MG TABLET 250 RC 0406051223 NDC outpatient 325 ME 2.14 1.71 Aetna Commercial PPO 1.18 percent of total billed charges 1.18 1.82 55 of billed Charges METOCLOPRAMIDE 5MG/ML 2ML INJ. J2765 HCPCS 250 RC 0409341401 NDC inpatient 10 ME 4.86 2.43 BCBS Louisiana PPO 2.43 percent of total billed charges 2.43 4.13 50% of Eligible Charges METOCLOPRAMIDE 5MG/ML 2ML INJ. J2765 HCPCS 250 RC 0409341401 NDC outpatient 10 ME 4.86 3.89 BCBS Louisiana PPO 3.89 percent of total billed charges 2.67 4.13 80% of billed charge METOCLOPRAMIDE 5MG/ML 2ML INJ. J2765 HCPCS 250 RC 0409341401 NDC outpatient 10 ME 4.86 3.89 Cigna Commercial PPO 2.67 percent of total billed charges 2.67 4.13 55% of Billed Charges METOCLOPRAMIDE 5MG/ML 2ML INJ. J2765 HCPCS 250 RC 0409341401 NDC inpatient 10 ME 4.86 2.43 IMA of Louisiana Commercial PPO 4.13 percent of total billed charges 2.43 4.13 Inpatient Reimbursement at 85% of Billed Charges METOCLOPRAMIDE 5MG/ML 2ML INJ. J2765 HCPCS 250 RC 0409341401 NDC outpatient 10 ME 4.86 3.89 IMA of Louisiana Commercial PPO 4.13 percent of total billed charges 2.67 4.13 Reimbursement at 85% of billed charges FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC inpatient 0.1 ME 17.27 8.64 BCBS Louisiana PPO 8.64 percent of total billed charges 8.64 14.68 50% of Eligible Charges FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC outpatient 0.1 ME 17.27 13.82 BCBS Louisiana PPO 13.82 percent of total billed charges 9.5 14.68 80% of billed charge FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC outpatient 0.1 ME 17.27 13.82 Cigna Commercial PPO 9.5 percent of total billed charges 9.5 14.68 55% of Billed Charges FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC inpatient 0.1 ME 17.27 8.64 IMA of Louisiana Commercial PPO 14.68 percent of total billed charges 8.64 14.68 Inpatient Reimbursement at 85% of Billed Charges FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC outpatient 0.1 ME 17.27 13.82 IMA of Louisiana Commercial PPO 14.68 percent of total billed charges 9.5 14.68 Reimbursement at 85% of billed charges FLUMAZENIL 0.1MG/ML 5ML 260 RC 3600014810 NDC outpatient 0.1 ME 17.27 13.82 Aetna Commercial PPO 9.5 percent of total billed charges 9.5 14.68 55 of billed Charges THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC inpatient 5000 UN 340.47 170.24 BCBS Louisiana PPO 170.24 percent of total billed charges 170.24 289.4 50% of Eligible Charges THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC outpatient 5000 UN 340.47 272.38 BCBS Louisiana PPO 272.38 percent of total billed charges 187.26 289.4 80% of billed charge THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC outpatient 5000 UN 340.47 272.38 Cigna Commercial PPO 187.26 percent of total billed charges 187.26 289.4 55% of Billed Charges THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC inpatient 5000 UN 340.47 170.24 IMA of Louisiana Commercial PPO 289.4 percent of total billed charges 170.24 289.4 Inpatient Reimbursement at 85% of Billed Charges THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC outpatient 5000 UN 340.47 272.38 IMA of Louisiana Commercial PPO 289.4 percent of total billed charges 187.26 289.4 Reimbursement at 85% of billed charges THROMBIN 5000 UNITS/VL 260 RC 6079321505 NDC outpatient 5000 UN 340.47 272.38 Aetna Commercial PPO 187.26 percent of total billed charges 187.26 289.4 55 of billed Charges KETOROLAC 30MG/ML 1ML J1885 HCPCS 250 RC 6332316243 NDC inpatient 30 ME 1.98 0.99 BCBS Louisiana PPO 0.99 percent of total billed charges 0.99 1.68 50% of Eligible Charges KETOROLAC 30MG/ML 1ML J1885 HCPCS 250 RC 6332316243 NDC outpatient 30 ME 1.98 1.58 BCBS Louisiana PPO 1.58 percent of total billed charges 1.09 1.68 80% of billed charge KETOROLAC 30MG/ML 1ML J1885 HCPCS 250 RC 6332316243 NDC outpatient 30 ME 1.98 1.58 Cigna Commercial PPO 1.09 percent of total billed charges 1.09 1.68 55% of Billed Charges KETOROLAC 30MG/ML 1ML J1885 HCPCS 250 RC 6332316243 NDC inpatient 30 ME 1.98 0.99 IMA of Louisiana Commercial PPO 1.68 percent of total billed charges 0.99 1.68 Inpatient Reimbursement at 85% of Billed Charges KETOROLAC 30MG/ML 1ML J1885 HCPCS 250 RC 6332316243 NDC outpatient 30 ME 1.98 1.58 IMA of Louisiana Commercial PPO 1.68 percent of total billed charges 1.09 1.68 Reimbursement at 85% of billed charges ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC inpatient 325 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC outpatient 325 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC outpatient 325 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC inpatient 325 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC outpatient 325 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ACETAMINOPHEN TABLET : 325MG 250 RC 0904677361 NDC outpatient 325 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC inpatient 75 ME 1.8 0.9 BCBS Louisiana PPO 0.9 percent of total billed charges 0.9 1.53 50% of Eligible Charges VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC outpatient 75 ME 1.8 1.44 BCBS Louisiana PPO 1.44 percent of total billed charges 0.99 1.53 80% of billed charge VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC outpatient 75 ME 1.8 1.44 Cigna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55% of Billed Charges VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC inpatient 75 ME 1.8 0.9 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.9 1.53 Inpatient Reimbursement at 85% of Billed Charges VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC outpatient 75 ME 1.8 1.44 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.99 1.53 Reimbursement at 85% of billed charges VENLAFAXINE XR 75MG CAPSULE 250 RC 6808470901 NDC outpatient 75 ME 1.8 1.44 Aetna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55 of billed Charges LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC inpatient 0.63 ME 550.3 275.15 BCBS Louisiana PPO 275.15 percent of total billed charges 275.15 467.76 50% of Eligible Charges LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC outpatient 0.63 ME 550.3 440.24 BCBS Louisiana PPO 440.24 percent of total billed charges 302.67 467.76 80% of billed charge LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC outpatient 0.63 ME 550.3 440.24 Cigna Commercial PPO 302.67 percent of total billed charges 302.67 467.76 55% of Billed Charges LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC inpatient 0.63 ME 550.3 275.15 IMA of Louisiana Commercial PPO 467.76 percent of total billed charges 275.15 467.76 Inpatient Reimbursement at 85% of Billed Charges LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC outpatient 0.63 ME 550.3 440.24 IMA of Louisiana Commercial PPO 467.76 percent of total billed charges 302.67 467.76 Reimbursement at 85% of billed charges LEVALBUTEROL 0.63MG 3ML INH NON-FORM 250 RC 6699302127 NDC outpatient 0.63 ME 550.3 440.24 Aetna Commercial PPO 302.67 percent of total billed charges 302.67 467.76 55 of billed Charges ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC inpatient 10 ML 133.5 66.75 BCBS Louisiana PPO 66.75 percent of total billed charges 66.75 113.48 50% of Eligible Charges ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC outpatient 10 ML 133.5 106.8 BCBS Louisiana PPO 106.8 percent of total billed charges 73.43 113.48 80% of billed charge ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC outpatient 10 ML 133.5 106.8 Cigna Commercial PPO 73.43 percent of total billed charges 73.43 113.48 55% of Billed Charges ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC inpatient 10 ML 133.5 66.75 IMA of Louisiana Commercial PPO 113.48 percent of total billed charges 66.75 113.48 Inpatient Reimbursement at 85% of Billed Charges ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC outpatient 10 ML 133.5 106.8 IMA of Louisiana Commercial PPO 113.48 percent of total billed charges 73.43 113.48 Reimbursement at 85% of billed charges ISOVUE-M 200 41% INJ : 10ML Q9966 HCPCS 636 RC 0270141111 NDC outpatient 10 ML 133.5 106.8 Aetna Commercial PPO 80.1 percent of total billed charges 73.43 113.48 60 Of Billed Charges NITROGLYCERIN 200MCG/ML 250ML J3490 HCPCS 260 RC 0338104902 NDC inpatient 250 ML 125.8 62.9 BCBS Louisiana PPO 62.9 percent of total billed charges 62.9 106.93 50% of Eligible Charges NITROGLYCERIN 200MCG/ML 250ML J3490 HCPCS 260 RC 0338104902 NDC outpatient 250 ML 125.8 100.64 BCBS Louisiana PPO 100.64 percent of total billed charges 69.19 106.93 80% of billed charge NITROGLYCERIN 200MCG/ML 250ML J3490 HCPCS 260 RC 0338104902 NDC outpatient 250 ML 125.8 100.64 Cigna Commercial PPO 69.19 percent of total billed charges 69.19 106.93 55% of Billed Charges NITROGLYCERIN 200MCG/ML 250ML J3490 HCPCS 260 RC 0338104902 NDC inpatient 250 ML 125.8 62.9 IMA of Louisiana Commercial PPO 106.93 percent of total billed charges 62.9 106.93 Inpatient Reimbursement at 85% of Billed Charges NITROGLYCERIN 200MCG/ML 250ML J3490 HCPCS 260 RC 0338104902 NDC outpatient 250 ML 125.8 100.64 IMA of Louisiana Commercial PPO 106.93 percent of total billed charges 69.19 106.93 Reimbursement at 85% of billed charges FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC inpatient 20 ME 4.2 2.1 BCBS Louisiana PPO 2.1 percent of total billed charges 2.1 3.57 50% of Eligible Charges FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC outpatient 20 ME 4.2 3.36 BCBS Louisiana PPO 3.36 percent of total billed charges 2.31 3.57 80% of billed charge FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC outpatient 20 ME 4.2 3.36 Cigna Commercial PPO 2.31 percent of total billed charges 2.31 3.57 55% of Billed Charges FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC inpatient 20 ME 4.2 2.1 IMA of Louisiana Commercial PPO 3.57 percent of total billed charges 2.1 3.57 Inpatient Reimbursement at 85% of Billed Charges FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC outpatient 20 ME 4.2 3.36 IMA of Louisiana Commercial PPO 3.57 percent of total billed charges 2.31 3.57 Reimbursement at 85% of billed charges FAMOTIDINE 10MG/ML 2ML INJ 260 RC 6332373916 NDC outpatient 20 ME 4.2 3.36 Aetna Commercial PPO 2.31 percent of total billed charges 2.31 3.57 55 of billed Charges GENTAMICIN 40MG/ML 2ML J1580 HCPCS 250 RC 6332301094 NDC inpatient 80 ME 6.73 3.37 BCBS Louisiana PPO 3.37 percent of total billed charges 3.37 5.72 50% of Eligible Charges GENTAMICIN 40MG/ML 2ML J1580 HCPCS 250 RC 6332301094 NDC outpatient 80 ME 6.73 5.38 BCBS Louisiana PPO 5.38 percent of total billed charges 3.7 5.72 80% of billed charge GENTAMICIN 40MG/ML 2ML J1580 HCPCS 250 RC 6332301094 NDC outpatient 80 ME 6.73 5.38 Cigna Commercial PPO 3.7 percent of total billed charges 3.7 5.72 55% of Billed Charges GENTAMICIN 40MG/ML 2ML J1580 HCPCS 250 RC 6332301094 NDC inpatient 80 ME 6.73 3.37 IMA of Louisiana Commercial PPO 5.72 percent of total billed charges 3.37 5.72 Inpatient Reimbursement at 85% of Billed Charges GENTAMICIN 40MG/ML 2ML J1580 HCPCS 250 RC 6332301094 NDC outpatient 80 ME 6.73 5.38 IMA of Louisiana Commercial PPO 5.72 percent of total billed charges 3.7 5.72 Reimbursement at 85% of billed charges MORPHINE 0.5MG/ML 10ML PF J2270 HCPCS 250 RC 0409381411 NDC inpatient 0.5 ME 166.8 83.4 BCBS Louisiana PPO 83.4 percent of total billed charges 83.4 141.78 50% of Eligible Charges MORPHINE 0.5MG/ML 10ML PF J2270 HCPCS 250 RC 0409381411 NDC outpatient 0.5 ME 166.8 133.44 BCBS Louisiana PPO 133.44 percent of total billed charges 91.74 141.78 80% of billed charge MORPHINE 0.5MG/ML 10ML PF J2270 HCPCS 250 RC 0409381411 NDC outpatient 0.5 ME 166.8 133.44 Cigna Commercial PPO 91.74 percent of total billed charges 91.74 141.78 55% of Billed Charges MORPHINE 0.5MG/ML 10ML PF J2270 HCPCS 250 RC 0409381411 NDC inpatient 0.5 ME 166.8 83.4 IMA of Louisiana Commercial PPO 141.78 percent of total billed charges 83.4 141.78 Inpatient Reimbursement at 85% of Billed Charges MORPHINE 0.5MG/ML 10ML PF J2270 HCPCS 250 RC 0409381411 NDC outpatient 0.5 ME 166.8 133.44 IMA of Louisiana Commercial PPO 141.78 percent of total billed charges 91.74 141.78 Reimbursement at 85% of billed charges TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC inpatient 32 F2 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC outpatient 32 F2 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC outpatient 32 F2 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC inpatient 32 F2 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC outpatient 32 F2 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TRIPLE ANTIBIOTIC OINT 1/32OZ 250 RC 4768222335 NDC outpatient 32 F2 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC inpatient 10 ME 1.85 0.93 BCBS Louisiana PPO 0.93 percent of total billed charges 0.93 1.57 50% of Eligible Charges ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC outpatient 10 ME 1.85 1.48 BCBS Louisiana PPO 1.48 percent of total billed charges 1.02 1.57 80% of billed charge ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC outpatient 10 ME 1.85 1.48 Cigna Commercial PPO 1.02 percent of total billed charges 1.02 1.57 55% of Billed Charges ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC inpatient 10 ME 1.85 0.93 IMA of Louisiana Commercial PPO 1.57 percent of total billed charges 0.93 1.57 Inpatient Reimbursement at 85% of Billed Charges ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC outpatient 10 ME 1.85 1.48 IMA of Louisiana Commercial PPO 1.57 percent of total billed charges 1.02 1.57 Reimbursement at 85% of billed charges ZETIA (EZETIMIBE) 10MG TABLET 250 RC 5965105230 NDC outpatient 10 ME 1.85 1.48 Aetna Commercial PPO 1.02 percent of total billed charges 1.02 1.57 55 of billed Charges PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC inpatient 1.25 ME 16.49 8.25 BCBS Louisiana PPO 8.25 percent of total billed charges 8.25 14.02 50% of Eligible Charges PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC outpatient 1.25 ME 16.49 13.19 BCBS Louisiana PPO 13.19 percent of total billed charges 9.07 14.02 80% of billed charge PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC outpatient 1.25 ME 16.49 13.19 Cigna Commercial PPO 9.07 percent of total billed charges 9.07 14.02 55% of Billed Charges PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC inpatient 1.25 ME 16.49 8.25 IMA of Louisiana Commercial PPO 14.02 percent of total billed charges 8.25 14.02 Inpatient Reimbursement at 85% of Billed Charges PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC outpatient 1.25 ME 16.49 13.19 IMA of Louisiana Commercial PPO 14.02 percent of total billed charges 9.07 14.02 Reimbursement at 85% of billed charges PREMARIN 1.25MG TAB NON-FORMULARY 250 RC 0485850017 NDC outpatient 1.25 ME 16.49 13.19 Aetna Commercial PPO 9.07 percent of total billed charges 9.07 14.02 55 of billed Charges OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC inpatient 325 ME 7.19 3.6 BCBS Louisiana PPO 3.6 percent of total billed charges 3.6 6.11 50% of Eligible Charges OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC outpatient 325 ME 7.19 5.75 BCBS Louisiana PPO 5.75 percent of total billed charges 3.95 6.11 80% of billed charge OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC outpatient 325 ME 7.19 5.75 Cigna Commercial PPO 3.95 percent of total billed charges 3.95 6.11 55% of Billed Charges OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC inpatient 325 ME 7.19 3.6 IMA of Louisiana Commercial PPO 6.11 percent of total billed charges 3.6 6.11 Inpatient Reimbursement at 85% of Billed Charges OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC outpatient 325 ME 7.19 5.75 IMA of Louisiana Commercial PPO 6.11 percent of total billed charges 3.95 6.11 Reimbursement at 85% of billed charges OXYCODONE/ACETAMINOPHEN 10/325MG TABLET 250 RC 0406052362 NDC outpatient 325 ME 7.19 5.75 Aetna Commercial PPO 3.95 percent of total billed charges 3.95 6.11 55 of billed Charges ATENOLOL 25MG TABLET 250 RC 5107975920 NDC inpatient 25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ATENOLOL 25MG TABLET 250 RC 5107975920 NDC outpatient 25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ATENOLOL 25MG TABLET 250 RC 5107975920 NDC outpatient 25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ATENOLOL 25MG TABLET 250 RC 5107975920 NDC inpatient 25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ATENOLOL 25MG TABLET 250 RC 5107975920 NDC outpatient 25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ATENOLOL 25MG TABLET 250 RC 5107975920 NDC outpatient 25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM CHL 0.9% 250ML ADD-BAG J7050 HCPCS 260 RC 0409710102 NDC inpatient 250 ML 21.85 10.93 BCBS Louisiana PPO 10.93 percent of total billed charges 10.93 18.57 50% of Eligible Charges SODIUM CHL 0.9% 250ML ADD-BAG J7050 HCPCS 260 RC 0409710102 NDC outpatient 250 ML 21.85 17.48 BCBS Louisiana PPO 17.48 percent of total billed charges 12.02 18.57 80% of billed charge SODIUM CHL 0.9% 250ML ADD-BAG J7050 HCPCS 260 RC 0409710102 NDC outpatient 250 ML 21.85 17.48 Cigna Commercial PPO 12.02 percent of total billed charges 12.02 18.57 55% of Billed Charges SODIUM CHL 0.9% 250ML ADD-BAG J7050 HCPCS 260 RC 0409710102 NDC inpatient 250 ML 21.85 10.93 IMA of Louisiana Commercial PPO 18.57 percent of total billed charges 10.93 18.57 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 250ML ADD-BAG J7050 HCPCS 260 RC 0409710102 NDC outpatient 250 ML 21.85 17.48 IMA of Louisiana Commercial PPO 18.57 percent of total billed charges 12.02 18.57 Reimbursement at 85% of billed charges COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC inpatient 0.6 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC outpatient 0.6 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC outpatient 0.6 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC inpatient 0.6 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC outpatient 0.6 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges COLCHICINE 0.6MG TABLET 250 RC 4229205403 NDC outpatient 0.6 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ALLOPURINOL 100MG TAB 250 RC 5107920501 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SIMVASTATIN 20MG TABLET 250 RC 6373957210 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 BCBS Louisiana PPO 235.47 percent of total billed charges 235.47 400.29 50% of Eligible Charges SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 BCBS Louisiana PPO 376.74 percent of total billed charges 174.24 400.29 80% of billed charge SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Cigna Commercial PPO 273.14 percent of total billed charges 174.24 400.29 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 235.47 400.29 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 174.24 400.29 Reimbursement at 85% of billed charges SCREW 4.0MM CANN. 34MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Aetna Commercial PPO 174.24 percent of total billed charges 174.24 400.29 37% Of Billed Charges 2000 SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 BCBS Louisiana PPO 235.47 percent of total billed charges 235.47 400.29 50% of Eligible Charges SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 BCBS Louisiana PPO 376.74 percent of total billed charges 174.24 400.29 80% of billed charge SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Cigna Commercial PPO 273.14 percent of total billed charges 174.24 400.29 58% of Billed Charges/$500 Threshold SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC inpatient 470.93 235.47 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 235.47 400.29 Inpatient Reimbursement at 85% of Billed Charges SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 IMA of Louisiana Commercial PPO 400.29 percent of total billed charges 174.24 400.29 Reimbursement at 85% of billed charges SCREW 4.0MM CANN. 46MM - SYNTHES C1713 HCPCS 278 RC outpatient 470.93 376.74 Aetna Commercial PPO 174.24 percent of total billed charges 174.24 400.29 37% Of Billed Charges 2000 ABDUCTION HIP PILLOW - SMALL 270 RC inpatient 131.78 65.89 BCBS Louisiana PPO 65.89 percent of total billed charges 65.89 112.01 50% of Eligible Charges ABDUCTION HIP PILLOW - SMALL 270 RC outpatient 131.78 105.42 BCBS Louisiana PPO 105.42 percent of total billed charges 72.48 112.01 80% of billed charge ABDUCTION HIP PILLOW - SMALL 270 RC outpatient 131.78 105.42 Cigna Commercial PPO 72.48 percent of total billed charges 72.48 112.01 55% of Billed Charges ABDUCTION HIP PILLOW - SMALL 270 RC inpatient 131.78 65.89 IMA of Louisiana Commercial PPO 112.01 percent of total billed charges 65.89 112.01 Inpatient Reimbursement at 85% of Billed Charges ABDUCTION HIP PILLOW - SMALL 270 RC outpatient 131.78 105.42 IMA of Louisiana Commercial PPO 112.01 percent of total billed charges 72.48 112.01 Reimbursement at 85% of billed charges ABDUCTION HIP PILLOW - SMALL 270 RC outpatient 131.78 105.42 Aetna Commercial PPO 72.48 percent of total billed charges 72.48 112.01 55 of billed Charges DRESSING XEROFORM 4 X 4 272 RC inpatient 4 2 BCBS Louisiana PPO 2 percent of total billed charges 2 3.4 50% of Eligible Charges DRESSING XEROFORM 4 X 4 272 RC outpatient 4 3.2 BCBS Louisiana PPO 3.2 percent of total billed charges 2.2 3.4 80% of billed charge DRESSING XEROFORM 4 X 4 272 RC outpatient 4 3.2 Cigna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55% of Billed Charges DRESSING XEROFORM 4 X 4 272 RC inpatient 4 2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2 3.4 Inpatient Reimbursement at 85% of Billed Charges DRESSING XEROFORM 4 X 4 272 RC outpatient 4 3.2 IMA of Louisiana Commercial PPO 3.4 percent of total billed charges 2.2 3.4 Reimbursement at 85% of billed charges DRESSING XEROFORM 4 X 4 272 RC outpatient 4 3.2 Aetna Commercial PPO 2.2 percent of total billed charges 2.2 3.4 55 of billed Charges INSTRUMENT MAGNET PAD 272 RC inpatient 548.15 274.08 BCBS Louisiana PPO 274.08 percent of total billed charges 274.08 465.93 50% of Eligible Charges INSTRUMENT MAGNET PAD 272 RC outpatient 548.15 438.52 BCBS Louisiana PPO 438.52 percent of total billed charges 301.48 465.93 80% of billed charge INSTRUMENT MAGNET PAD 272 RC outpatient 548.15 438.52 Cigna Commercial PPO 301.48 percent of total billed charges 301.48 465.93 55% of Billed Charges INSTRUMENT MAGNET PAD 272 RC inpatient 548.15 274.08 IMA of Louisiana Commercial PPO 465.93 percent of total billed charges 274.08 465.93 Inpatient Reimbursement at 85% of Billed Charges INSTRUMENT MAGNET PAD 272 RC outpatient 548.15 438.52 IMA of Louisiana Commercial PPO 465.93 percent of total billed charges 301.48 465.93 Reimbursement at 85% of billed charges INSTRUMENT MAGNET PAD 272 RC outpatient 548.15 438.52 Aetna Commercial PPO 301.48 percent of total billed charges 301.48 465.93 55 of billed Charges FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC inpatient 1500 750 BCBS Louisiana PPO 750 percent of total billed charges 750 1275 50% of Eligible Charges FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC outpatient 1500 1200 BCBS Louisiana PPO 1200 percent of total billed charges 555 1275 80% of billed charge FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC outpatient 1500 1200 Cigna Commercial PPO 870 percent of total billed charges 555 1275 58% of Billed Charges/$500 Threshold FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC inpatient 1500 750 IMA of Louisiana Commercial PPO 1275 percent of total billed charges 750 1275 Inpatient Reimbursement at 85% of Billed Charges FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC outpatient 1500 1200 IMA of Louisiana Commercial PPO 1275 percent of total billed charges 555 1275 Reimbursement at 85% of billed charges FEMORAL HEAD BONE GRAFT 44/46MM C1713 HCPCS 278 RC outpatient 1500 1200 Aetna Commercial PPO 555 percent of total billed charges 555 1275 37% Of Billed Charges 2000 LEG BAG ACCESSORY 270 RC inpatient 15.32 7.66 BCBS Louisiana PPO 7.66 percent of total billed charges 7.66 13.02 50% of Eligible Charges LEG BAG ACCESSORY 270 RC outpatient 15.32 12.26 BCBS Louisiana PPO 12.26 percent of total billed charges 8.43 13.02 80% of billed charge LEG BAG ACCESSORY 270 RC outpatient 15.32 12.26 Cigna Commercial PPO 8.43 percent of total billed charges 8.43 13.02 55% of Billed Charges LEG BAG ACCESSORY 270 RC inpatient 15.32 7.66 IMA of Louisiana Commercial PPO 13.02 percent of total billed charges 7.66 13.02 Inpatient Reimbursement at 85% of Billed Charges LEG BAG ACCESSORY 270 RC outpatient 15.32 12.26 IMA of Louisiana Commercial PPO 13.02 percent of total billed charges 8.43 13.02 Reimbursement at 85% of billed charges LEG BAG ACCESSORY 270 RC outpatient 15.32 12.26 Aetna Commercial PPO 8.43 percent of total billed charges 8.43 13.02 55 of billed Charges VALVE ANTI-REFLUX KEITH ARV 270 RC inpatient 153.76 76.88 BCBS Louisiana PPO 76.88 percent of total billed charges 76.88 130.7 50% of Eligible Charges VALVE ANTI-REFLUX KEITH ARV 270 RC outpatient 153.76 123.01 BCBS Louisiana PPO 123.01 percent of total billed charges 84.57 130.7 80% of billed charge VALVE ANTI-REFLUX KEITH ARV 270 RC outpatient 153.76 123.01 Cigna Commercial PPO 84.57 percent of total billed charges 84.57 130.7 55% of Billed Charges VALVE ANTI-REFLUX KEITH ARV 270 RC inpatient 153.76 76.88 IMA of Louisiana Commercial PPO 130.7 percent of total billed charges 76.88 130.7 Inpatient Reimbursement at 85% of Billed Charges VALVE ANTI-REFLUX KEITH ARV 270 RC outpatient 153.76 123.01 IMA of Louisiana Commercial PPO 130.7 percent of total billed charges 84.57 130.7 Reimbursement at 85% of billed charges VALVE ANTI-REFLUX KEITH ARV 270 RC outpatient 153.76 123.01 Aetna Commercial PPO 84.57 percent of total billed charges 84.57 130.7 55 of billed Charges STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC inpatient 265.02 132.51 BCBS Louisiana PPO 132.51 percent of total billed charges 132.51 225.27 50% of Eligible Charges STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC outpatient 265.02 212.02 BCBS Louisiana PPO 212.02 percent of total billed charges 145.76 225.27 80% of billed charge STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC outpatient 265.02 212.02 Cigna Commercial PPO 145.76 percent of total billed charges 145.76 225.27 55% of Billed Charges STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC inpatient 265.02 132.51 IMA of Louisiana Commercial PPO 225.27 percent of total billed charges 132.51 225.27 Inpatient Reimbursement at 85% of Billed Charges STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC outpatient 265.02 212.02 IMA of Louisiana Commercial PPO 225.27 percent of total billed charges 145.76 225.27 Reimbursement at 85% of billed charges STOCKING ANTI-EMBOLISM LONG THIGH SM 270 RC outpatient 265.02 212.02 Aetna Commercial PPO 145.76 percent of total billed charges 145.76 225.27 55 of billed Charges BLOCK WITH SEDATION - SUPPLIES 270 RC inpatient 100 50 BCBS Louisiana PPO 50 percent of total billed charges 50 85 50% of Eligible Charges BLOCK WITH SEDATION - SUPPLIES 270 RC outpatient 100 80 BCBS Louisiana PPO 80 percent of total billed charges 55 85 80% of billed charge BLOCK WITH SEDATION - SUPPLIES 270 RC outpatient 100 80 Cigna Commercial PPO 55 percent of total billed charges 55 85 55% of Billed Charges BLOCK WITH SEDATION - SUPPLIES 270 RC inpatient 100 50 IMA of Louisiana Commercial PPO 85 percent of total billed charges 50 85 Inpatient Reimbursement at 85% of Billed Charges BLOCK WITH SEDATION - SUPPLIES 270 RC outpatient 100 80 IMA of Louisiana Commercial PPO 85 percent of total billed charges 55 85 Reimbursement at 85% of billed charges BLOCK WITH SEDATION - SUPPLIES 270 RC outpatient 100 80 Aetna Commercial PPO 55 percent of total billed charges 55 85 55 of billed Charges PICC LINE DECLOTTING 36593 CPT 360 RC inpatient 743.93 371.97 BCBS Louisiana PPO 371.97 percent of total billed charges 371.97 632.34 50% of Eligible Charges PICC LINE DECLOTTING 36593 CPT 360 RC outpatient 743.93 595.14 BCBS Louisiana PPO 595.14 percent of total billed charges 409.16 1300 80% of billed charges PICC LINE DECLOTTING 36593 CPT 360 RC outpatient 743.93 595.14 Cigna Commercial PPO 409.16 percent of total billed charges 409.16 1300 55% of Billed Charges PICC LINE DECLOTTING 36593 CPT 360 RC inpatient 743.93 371.97 IMA of Louisiana Commercial PPO 632.34 percent of total billed charges 371.97 632.34 Inpatient Reimbursement at 85% of Billed Charges PICC LINE DECLOTTING 36593 CPT 360 RC outpatient 743.93 595.14 IMA of Louisiana Commercial PPO 632.34 percent of total billed charges 409.16 1300 Reimbursement at 85% of billed charges PICC LINE DECLOTTING 36593 CPT 360 RC outpatient 743.93 595.14 Aetna Commercial PPO 1300 fee schedule 409.16 1300 Case Rate PICC LINE EVALUATION 260 RC inpatient 210 105 BCBS Louisiana PPO 105 percent of total billed charges 105 178.5 50% of Eligible Charges PICC LINE EVALUATION 260 RC outpatient 210 168 BCBS Louisiana PPO 168 percent of total billed charges 115.5 178.5 80% of billed charge PICC LINE EVALUATION 260 RC outpatient 210 168 Cigna Commercial PPO 115.5 percent of total billed charges 115.5 178.5 55% of Billed Charges PICC LINE EVALUATION 260 RC inpatient 210 105 IMA of Louisiana Commercial PPO 178.5 percent of total billed charges 105 178.5 Inpatient Reimbursement at 85% of Billed Charges PICC LINE EVALUATION 260 RC outpatient 210 168 IMA of Louisiana Commercial PPO 178.5 percent of total billed charges 115.5 178.5 Reimbursement at 85% of billed charges PICC LINE EVALUATION 260 RC outpatient 210 168 Aetna Commercial PPO 115.5 percent of total billed charges 115.5 178.5 55 of billed Charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC inpatient 611.75 305.88 BCBS Louisiana PPO 305.88 percent of total billed charges 305.88 519.99 50% of Eligible Charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC outpatient 611.75 489.4 BCBS Louisiana PPO 489.4 percent of total billed charges 336.46 1300 80% of billed charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC outpatient 611.75 489.4 Cigna Commercial PPO 336.46 percent of total billed charges 336.46 1300 55% of Billed Charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC inpatient 611.75 305.88 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 305.88 519.99 Inpatient Reimbursement at 85% of Billed Charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC outpatient 611.75 489.4 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 336.46 1300 Reimbursement at 85% of billed charges "DRAIN/INJECT, JOINT/BURSA" 20610 CPT 360 RC outpatient 611.75 489.4 Aetna Commercial PPO 1300 fee schedule 336.46 1300 Case Rate COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC inpatient 1072.45 536.23 BCBS Louisiana PPO 536.23 percent of total billed charges 536.23 911.58 50% of Eligible Charges COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC outpatient 1072.45 857.96 BCBS Louisiana PPO 857.96 percent of total billed charges 589.85 1300 80% of billed charges COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC outpatient 1072.45 857.96 Cigna Commercial PPO 589.85 percent of total billed charges 589.85 1300 55% of Billed Charges COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC inpatient 1072.45 536.23 IMA of Louisiana Commercial PPO 911.58 percent of total billed charges 536.23 911.58 Inpatient Reimbursement at 85% of Billed Charges COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC outpatient 1072.45 857.96 IMA of Louisiana Commercial PPO 911.58 percent of total billed charges 589.85 1300 Reimbursement at 85% of billed charges COMP ASST MUSCKEL SURG NAVIGA W/CT/MRI 20985 CPT 360 RC outpatient 1072.45 857.96 Aetna Commercial PPO 1300 fee schedule 589.85 1300 Case Rate PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP inpatient 94.95 47.48 BCBS Louisiana PPO 47.48 percent of total billed charges 47.48 80.71 50% of Eligible Charges PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP outpatient 94.95 75.96 BCBS Louisiana PPO 75.96 percent of total billed charges 52.22 85 80% of billed charge PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP outpatient 94.95 75.96 Cigna Commercial PPO 85 other 52.22 85 63% of Billed Charges PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP inpatient 94.95 47.48 IMA of Louisiana Commercial PPO 80.71 percent of total billed charges 47.48 80.71 Inpatient Reimbursement at 85% of Billed Charges PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP outpatient 94.95 75.96 IMA of Louisiana Commercial PPO 80.71 percent of total billed charges 52.22 85 Reimbursement at 85% of billed charges PHYSICAL THERAPY PERFORMANCE TEST 97750 CPT 421 RC GP outpatient 94.95 75.96 Aetna Commercial PPO 52.22 percent of total billed charges 52.22 85 55 of billed Charges PT ROM 95851 CPT 421 RC "GP,59" inpatient 19.9 9.95 BCBS Louisiana PPO 9.95 percent of total billed charges 9.95 16.92 50% of Eligible Charges PT ROM 95851 CPT 421 RC "GP,59" outpatient 19.9 15.92 BCBS Louisiana PPO 15.92 percent of total billed charges 10.95 85 80% of billed charge PT ROM 95851 CPT 421 RC "GP,59" outpatient 19.9 15.92 Cigna Commercial PPO 85 other 10.95 85 63% of Billed Charges PT ROM 95851 CPT 421 RC "GP,59" inpatient 19.9 9.95 IMA of Louisiana Commercial PPO 16.92 percent of total billed charges 9.95 16.92 Inpatient Reimbursement at 85% of Billed Charges PT ROM 95851 CPT 421 RC "GP,59" outpatient 19.9 15.92 IMA of Louisiana Commercial PPO 16.92 percent of total billed charges 10.95 85 Reimbursement at 85% of billed charges PT ROM 95851 CPT 421 RC "GP,59" outpatient 19.9 15.92 Aetna Commercial PPO 10.95 percent of total billed charges 10.95 85 55 of billed Charges PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP inpatient 211.98 105.99 BCBS Louisiana PPO 105.99 percent of total billed charges 105.99 180.18 50% of Eligible Charges PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP outpatient 211.98 169.58 BCBS Louisiana PPO 169.58 percent of total billed charges 85 180.18 80% of billed charge PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP outpatient 211.98 169.58 Cigna Commercial PPO 85 other 85 180.18 63% of Billed Charges PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP inpatient 211.98 105.99 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 105.99 180.18 Inpatient Reimbursement at 85% of Billed Charges PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP outpatient 211.98 169.58 IMA of Louisiana Commercial PPO 180.18 percent of total billed charges 85 180.18 Reimbursement at 85% of billed charges PT EVAL LOW COMPLEX 20 MIN 97161 CPT 424 RC GP outpatient 211.98 169.58 Aetna Commercial PPO 158.42 fee schedule 85 180.18 200% Of Aetna Market Fee Schedule CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC inpatient 3425.43 1712.72 BCBS Louisiana PPO 1712.72 percent of total billed charges 1712.72 2911.62 50% of Eligible Charges CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC outpatient 3425.43 2740.34 BCBS Louisiana PPO 2740.34 percent of total billed charges 1300 2911.62 80% of billed charges CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC outpatient 3425.43 2740.34 Cigna Commercial PPO 1883.99 percent of total billed charges 1300 2911.62 55% of Billed Charges CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC inpatient 3425.43 1712.72 IMA of Louisiana Commercial PPO 2911.62 percent of total billed charges 1712.72 2911.62 Inpatient Reimbursement at 85% of Billed Charges CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC outpatient 3425.43 2740.34 IMA of Louisiana Commercial PPO 2911.62 percent of total billed charges 1300 2911.62 Reimbursement at 85% of billed charges CLSD TX SHOULDER DISCLC W/ MANIPULATION 23655 CPT 360 RC outpatient 3425.43 2740.34 Aetna Commercial PPO 1300 fee schedule 1300 2911.62 Case Rate SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 BCBS Louisiana PPO 57.44 percent of total billed charges 57.44 97.64 50% of Eligible Charges SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 BCBS Louisiana PPO 91.9 percent of total billed charges 42.5 97.64 80% of billed charge SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Cigna Commercial PPO 66.62 percent of total billed charges 42.5 97.64 58% of Billed Charges/$500 Threshold SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC inpatient 114.87 57.44 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 57.44 97.64 Inpatient Reimbursement at 85% of Billed Charges SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 IMA of Louisiana Commercial PPO 97.64 percent of total billed charges 42.5 97.64 Reimbursement at 85% of billed charges SCREW 2.0MM CORTEX 11MM MOD HAND - SYN C1713 HCPCS 278 RC outpatient 114.87 91.9 Aetna Commercial PPO 42.5 percent of total billed charges 42.5 97.64 37% Of Billed Charges 2000 PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 827.34 413.67 BCBS Louisiana PPO 413.67 percent of total billed charges 413.67 703.24 50% of Eligible Charges PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 827.34 661.87 BCBS Louisiana PPO 661.87 percent of total billed charges 306.12 703.24 80% of billed charge PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 827.34 661.87 Cigna Commercial PPO 479.86 percent of total billed charges 306.12 703.24 58% of Billed Charges/$500 Threshold PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC inpatient 827.34 413.67 IMA of Louisiana Commercial PPO 703.24 percent of total billed charges 413.67 703.24 Inpatient Reimbursement at 85% of Billed Charges PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 827.34 661.87 IMA of Louisiana Commercial PPO 703.24 percent of total billed charges 306.12 703.24 Reimbursement at 85% of billed charges PLATE 2.0MM LC0DCP 8 HOLE - SYNTHES C1713 HCPCS 278 RC outpatient 827.34 661.87 Aetna Commercial PPO 306.12 percent of total billed charges 306.12 703.24 37% Of Billed Charges 2000 BUR DIAMOND WHEEL #MC254 272 RC inpatient 450.45 225.23 BCBS Louisiana PPO 225.23 percent of total billed charges 225.23 382.88 50% of Eligible Charges BUR DIAMOND WHEEL #MC254 272 RC outpatient 450.45 360.36 BCBS Louisiana PPO 360.36 percent of total billed charges 247.75 382.88 80% of billed charge BUR DIAMOND WHEEL #MC254 272 RC outpatient 450.45 360.36 Cigna Commercial PPO 247.75 percent of total billed charges 247.75 382.88 55% of Billed Charges BUR DIAMOND WHEEL #MC254 272 RC inpatient 450.45 225.23 IMA of Louisiana Commercial PPO 382.88 percent of total billed charges 225.23 382.88 Inpatient Reimbursement at 85% of Billed Charges BUR DIAMOND WHEEL #MC254 272 RC outpatient 450.45 360.36 IMA of Louisiana Commercial PPO 382.88 percent of total billed charges 247.75 382.88 Reimbursement at 85% of billed charges BUR DIAMOND WHEEL #MC254 272 RC outpatient 450.45 360.36 Aetna Commercial PPO 247.75 percent of total billed charges 247.75 382.88 55 of billed Charges URINARY LEG BAG 1000ML 270 RC inpatient 224 112 BCBS Louisiana PPO 112 percent of total billed charges 112 190.4 50% of Eligible Charges URINARY LEG BAG 1000ML 270 RC outpatient 224 179.2 BCBS Louisiana PPO 179.2 percent of total billed charges 123.2 190.4 80% of billed charge URINARY LEG BAG 1000ML 270 RC outpatient 224 179.2 Cigna Commercial PPO 123.2 percent of total billed charges 123.2 190.4 55% of Billed Charges URINARY LEG BAG 1000ML 270 RC inpatient 224 112 IMA of Louisiana Commercial PPO 190.4 percent of total billed charges 112 190.4 Inpatient Reimbursement at 85% of Billed Charges URINARY LEG BAG 1000ML 270 RC outpatient 224 179.2 IMA of Louisiana Commercial PPO 190.4 percent of total billed charges 123.2 190.4 Reimbursement at 85% of billed charges URINARY LEG BAG 1000ML 270 RC outpatient 224 179.2 Aetna Commercial PPO 123.2 percent of total billed charges 123.2 190.4 55 of billed Charges UROLOGISTS TRAY 272 RC inpatient 445.5 222.75 BCBS Louisiana PPO 222.75 percent of total billed charges 222.75 378.68 50% of Eligible Charges UROLOGISTS TRAY 272 RC outpatient 445.5 356.4 BCBS Louisiana PPO 356.4 percent of total billed charges 245.03 378.68 80% of billed charge UROLOGISTS TRAY 272 RC outpatient 445.5 356.4 Cigna Commercial PPO 245.03 percent of total billed charges 245.03 378.68 55% of Billed Charges UROLOGISTS TRAY 272 RC inpatient 445.5 222.75 IMA of Louisiana Commercial PPO 378.68 percent of total billed charges 222.75 378.68 Inpatient Reimbursement at 85% of Billed Charges UROLOGISTS TRAY 272 RC outpatient 445.5 356.4 IMA of Louisiana Commercial PPO 378.68 percent of total billed charges 245.03 378.68 Reimbursement at 85% of billed charges UROLOGISTS TRAY 272 RC outpatient 445.5 356.4 Aetna Commercial PPO 245.03 percent of total billed charges 245.03 378.68 55 of billed Charges NEEDLE KEITH SZ 5 272 RC inpatient 749.68 374.84 BCBS Louisiana PPO 374.84 percent of total billed charges 374.84 637.23 50% of Eligible Charges NEEDLE KEITH SZ 5 272 RC outpatient 749.68 599.74 BCBS Louisiana PPO 599.74 percent of total billed charges 412.32 637.23 80% of billed charge NEEDLE KEITH SZ 5 272 RC outpatient 749.68 599.74 Cigna Commercial PPO 412.32 percent of total billed charges 412.32 637.23 55% of Billed Charges NEEDLE KEITH SZ 5 272 RC inpatient 749.68 374.84 IMA of Louisiana Commercial PPO 637.23 percent of total billed charges 374.84 637.23 Inpatient Reimbursement at 85% of Billed Charges NEEDLE KEITH SZ 5 272 RC outpatient 749.68 599.74 IMA of Louisiana Commercial PPO 637.23 percent of total billed charges 412.32 637.23 Reimbursement at 85% of billed charges NEEDLE KEITH SZ 5 272 RC outpatient 749.68 599.74 Aetna Commercial PPO 412.32 percent of total billed charges 412.32 637.23 55 of billed Charges SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC inpatient 594 297 BCBS Louisiana PPO 297 percent of total billed charges 297 504.9 50% of Eligible Charges SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC outpatient 594 475.2 BCBS Louisiana PPO 475.2 percent of total billed charges 326.7 504.9 80% of billed charge SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC outpatient 594 475.2 Cigna Commercial PPO 326.7 percent of total billed charges 326.7 504.9 55% of Billed Charges SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC inpatient 594 297 IMA of Louisiana Commercial PPO 504.9 percent of total billed charges 297 504.9 Inpatient Reimbursement at 85% of Billed Charges SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC outpatient 594 475.2 IMA of Louisiana Commercial PPO 504.9 percent of total billed charges 326.7 504.9 Reimbursement at 85% of billed charges SUTURE FIBERWIRE 4-0 AR-7230-01 272 RC outpatient 594 475.2 Aetna Commercial PPO 326.7 percent of total billed charges 326.7 504.9 55 of billed Charges SAW BLADE 2108-127-070 272 RC inpatient 313.43 156.72 BCBS Louisiana PPO 156.72 percent of total billed charges 156.72 266.42 50% of Eligible Charges SAW BLADE 2108-127-070 272 RC outpatient 313.43 250.74 BCBS Louisiana PPO 250.74 percent of total billed charges 172.39 266.42 80% of billed charge SAW BLADE 2108-127-070 272 RC outpatient 313.43 250.74 Cigna Commercial PPO 172.39 percent of total billed charges 172.39 266.42 55% of Billed Charges SAW BLADE 2108-127-070 272 RC inpatient 313.43 156.72 IMA of Louisiana Commercial PPO 266.42 percent of total billed charges 156.72 266.42 Inpatient Reimbursement at 85% of Billed Charges SAW BLADE 2108-127-070 272 RC outpatient 313.43 250.74 IMA of Louisiana Commercial PPO 266.42 percent of total billed charges 172.39 266.42 Reimbursement at 85% of billed charges SAW BLADE 2108-127-070 272 RC outpatient 313.43 250.74 Aetna Commercial PPO 172.39 percent of total billed charges 172.39 266.42 55 of billed Charges ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC inpatient 525 262.5 BCBS Louisiana PPO 262.5 percent of total billed charges 262.5 446.25 50% of Eligible Charges ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC outpatient 525 420 BCBS Louisiana PPO 420 percent of total billed charges 194.25 446.25 80% of billed charge ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC outpatient 525 420 Cigna Commercial PPO 304.5 percent of total billed charges 194.25 446.25 58% of Billed Charges/$500 Threshold ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC inpatient 525 262.5 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 262.5 446.25 Inpatient Reimbursement at 85% of Billed Charges ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC outpatient 525 420 IMA of Louisiana Commercial PPO 446.25 percent of total billed charges 194.25 446.25 Reimbursement at 85% of billed charges ANCHOR 4.5 FOOTPRINT #72202901 - S&N END C1713 HCPCS 278 RC outpatient 525 420 Aetna Commercial PPO 194.25 percent of total billed charges 194.25 446.25 37% Of Billed Charges 2000 PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC inpatient 1499.68 749.84 BCBS Louisiana PPO 749.84 percent of total billed charges 749.84 1274.73 50% of Eligible Charges PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC outpatient 1499.68 1199.74 BCBS Louisiana PPO 1199.74 percent of total billed charges 824.82 1274.73 80% of billed charge PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC outpatient 1499.68 1199.74 Cigna Commercial PPO 824.82 percent of total billed charges 824.82 1274.73 55% of Billed Charges PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC inpatient 1499.68 749.84 IMA of Louisiana Commercial PPO 1274.73 percent of total billed charges 749.84 1274.73 Inpatient Reimbursement at 85% of Billed Charges PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC outpatient 1499.68 1199.74 IMA of Louisiana Commercial PPO 1274.73 percent of total billed charges 824.82 1274.73 Reimbursement at 85% of billed charges PEEL AWAY FLYTE SHIELDS - STRYKER 272 RC outpatient 1499.68 1199.74 Aetna Commercial PPO 824.82 percent of total billed charges 824.82 1274.73 55 of billed Charges CANNULA FLEX 6.5 X 72MM - S&N 272 RC inpatient 562.5 281.25 BCBS Louisiana PPO 281.25 percent of total billed charges 281.25 478.13 50% of Eligible Charges CANNULA FLEX 6.5 X 72MM - S&N 272 RC outpatient 562.5 450 BCBS Louisiana PPO 450 percent of total billed charges 309.38 478.13 80% of billed charge CANNULA FLEX 6.5 X 72MM - S&N 272 RC outpatient 562.5 450 Cigna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55% of Billed Charges CANNULA FLEX 6.5 X 72MM - S&N 272 RC inpatient 562.5 281.25 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 281.25 478.13 Inpatient Reimbursement at 85% of Billed Charges CANNULA FLEX 6.5 X 72MM - S&N 272 RC outpatient 562.5 450 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 309.38 478.13 Reimbursement at 85% of billed charges CANNULA FLEX 6.5 X 72MM - S&N 272 RC outpatient 562.5 450 Aetna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55 of billed Charges GLOVE SENSICARE 7 1/2 272 RC inpatient 17.18 8.59 BCBS Louisiana PPO 8.59 percent of total billed charges 8.59 14.6 50% of Eligible Charges GLOVE SENSICARE 7 1/2 272 RC outpatient 17.18 13.74 BCBS Louisiana PPO 13.74 percent of total billed charges 9.45 14.6 80% of billed charge GLOVE SENSICARE 7 1/2 272 RC outpatient 17.18 13.74 Cigna Commercial PPO 9.45 percent of total billed charges 9.45 14.6 55% of Billed Charges GLOVE SENSICARE 7 1/2 272 RC inpatient 17.18 8.59 IMA of Louisiana Commercial PPO 14.6 percent of total billed charges 8.59 14.6 Inpatient Reimbursement at 85% of Billed Charges GLOVE SENSICARE 7 1/2 272 RC outpatient 17.18 13.74 IMA of Louisiana Commercial PPO 14.6 percent of total billed charges 9.45 14.6 Reimbursement at 85% of billed charges GLOVE SENSICARE 7 1/2 272 RC outpatient 17.18 13.74 Aetna Commercial PPO 9.45 percent of total billed charges 9.45 14.6 55 of billed Charges INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC inpatient 7600 3800 BCBS Louisiana PPO 3800 percent of total billed charges 3800 6460 50% of Eligible Charges INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC outpatient 7600 6080 BCBS Louisiana PPO 6080 percent of total billed charges 2812 6460 80% of billed charge INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC outpatient 7600 6080 Cigna Commercial PPO 4408 percent of total billed charges 2812 6460 58% of Billed Charges/$500 Threshold INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC inpatient 7600 3800 IMA of Louisiana Commercial PPO 6460 percent of total billed charges 3800 6460 Inpatient Reimbursement at 85% of Billed Charges INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC outpatient 7600 6080 IMA of Louisiana Commercial PPO 6460 percent of total billed charges 2812 6460 Reimbursement at 85% of billed charges INFUSE BONE GRAFT KIT LARGE II-SHS PRODU C1713 HCPCS 278 RC outpatient 7600 6080 Aetna Commercial PPO 2812 percent of total billed charges 2812 6460 37% Of Billed Charges 2000 BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC inpatient 240.21 120.11 BCBS Louisiana PPO 120.11 percent of total billed charges 120.11 204.18 50% of Eligible Charges BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC outpatient 240.21 192.17 BCBS Louisiana PPO 192.17 percent of total billed charges 132.12 204.18 80% of billed charge BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC outpatient 240.21 192.17 Cigna Commercial PPO 132.12 percent of total billed charges 132.12 204.18 55% of Billed Charges BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC inpatient 240.21 120.11 IMA of Louisiana Commercial PPO 204.18 percent of total billed charges 120.11 204.18 Inpatient Reimbursement at 85% of Billed Charges BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC outpatient 240.21 192.17 IMA of Louisiana Commercial PPO 204.18 percent of total billed charges 132.12 204.18 Reimbursement at 85% of billed charges BLADE SAW - TOTAL ANKLE 5100-337-233 272 RC outpatient 240.21 192.17 Aetna Commercial PPO 132.12 percent of total billed charges 132.12 204.18 55 of billed Charges ENDOSCOPIC KITTNER - CAMPBELL 272 RC inpatient 175 87.5 BCBS Louisiana PPO 87.5 percent of total billed charges 87.5 148.75 50% of Eligible Charges ENDOSCOPIC KITTNER - CAMPBELL 272 RC outpatient 175 140 BCBS Louisiana PPO 140 percent of total billed charges 96.25 148.75 80% of billed charge ENDOSCOPIC KITTNER - CAMPBELL 272 RC outpatient 175 140 Cigna Commercial PPO 96.25 percent of total billed charges 96.25 148.75 55% of Billed Charges ENDOSCOPIC KITTNER - CAMPBELL 272 RC inpatient 175 87.5 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 87.5 148.75 Inpatient Reimbursement at 85% of Billed Charges ENDOSCOPIC KITTNER - CAMPBELL 272 RC outpatient 175 140 IMA of Louisiana Commercial PPO 148.75 percent of total billed charges 96.25 148.75 Reimbursement at 85% of billed charges ENDOSCOPIC KITTNER - CAMPBELL 272 RC outpatient 175 140 Aetna Commercial PPO 96.25 percent of total billed charges 96.25 148.75 55 of billed Charges BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC inpatient 237.51 118.76 BCBS Louisiana PPO 118.76 percent of total billed charges 118.76 201.88 50% of Eligible Charges BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC outpatient 237.51 190.01 BCBS Louisiana PPO 190.01 percent of total billed charges 130.63 201.88 80% of billed charge BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC outpatient 237.51 190.01 Cigna Commercial PPO 130.63 percent of total billed charges 130.63 201.88 55% of Billed Charges BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC inpatient 237.51 118.76 IMA of Louisiana Commercial PPO 201.88 percent of total billed charges 118.76 201.88 Inpatient Reimbursement at 85% of Billed Charges BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC outpatient 237.51 190.01 IMA of Louisiana Commercial PPO 201.88 percent of total billed charges 130.63 201.88 Reimbursement at 85% of billed charges BURR BALL ANSPACH 6MM FLUTED - MAKO 272 RC outpatient 237.51 190.01 Aetna Commercial PPO 130.63 percent of total billed charges 130.63 201.88 55 of billed Charges CATHETER ANGIO 18G X 2 1/2 272 RC inpatient 257.25 128.63 BCBS Louisiana PPO 128.63 percent of total billed charges 128.63 218.66 50% of Eligible Charges CATHETER ANGIO 18G X 2 1/2 272 RC outpatient 257.25 205.8 BCBS Louisiana PPO 205.8 percent of total billed charges 141.49 218.66 80% of billed charge CATHETER ANGIO 18G X 2 1/2 272 RC outpatient 257.25 205.8 Cigna Commercial PPO 141.49 percent of total billed charges 141.49 218.66 55% of Billed Charges CATHETER ANGIO 18G X 2 1/2 272 RC inpatient 257.25 128.63 IMA of Louisiana Commercial PPO 218.66 percent of total billed charges 128.63 218.66 Inpatient Reimbursement at 85% of Billed Charges CATHETER ANGIO 18G X 2 1/2 272 RC outpatient 257.25 205.8 IMA of Louisiana Commercial PPO 218.66 percent of total billed charges 141.49 218.66 Reimbursement at 85% of billed charges CATHETER ANGIO 18G X 2 1/2 272 RC outpatient 257.25 205.8 Aetna Commercial PPO 141.49 percent of total billed charges 141.49 218.66 55 of billed Charges MIAMI J COLLAR STOUT 270 RC inpatient 186.2 93.1 BCBS Louisiana PPO 93.1 percent of total billed charges 93.1 158.27 50% of Eligible Charges MIAMI J COLLAR STOUT 270 RC outpatient 186.2 148.96 BCBS Louisiana PPO 148.96 percent of total billed charges 102.41 158.27 80% of billed charge MIAMI J COLLAR STOUT 270 RC outpatient 186.2 148.96 Cigna Commercial PPO 102.41 percent of total billed charges 102.41 158.27 55% of Billed Charges MIAMI J COLLAR STOUT 270 RC inpatient 186.2 93.1 IMA of Louisiana Commercial PPO 158.27 percent of total billed charges 93.1 158.27 Inpatient Reimbursement at 85% of Billed Charges MIAMI J COLLAR STOUT 270 RC outpatient 186.2 148.96 IMA of Louisiana Commercial PPO 158.27 percent of total billed charges 102.41 158.27 Reimbursement at 85% of billed charges MIAMI J COLLAR STOUT 270 RC outpatient 186.2 148.96 Aetna Commercial PPO 102.41 percent of total billed charges 102.41 158.27 55 of billed Charges DRESSING MEPILEX W/AG #498450 272 RC inpatient 128.8 64.4 BCBS Louisiana PPO 64.4 percent of total billed charges 64.4 109.48 50% of Eligible Charges DRESSING MEPILEX W/AG #498450 272 RC outpatient 128.8 103.04 BCBS Louisiana PPO 103.04 percent of total billed charges 70.84 109.48 80% of billed charge DRESSING MEPILEX W/AG #498450 272 RC outpatient 128.8 103.04 Cigna Commercial PPO 70.84 percent of total billed charges 70.84 109.48 55% of Billed Charges DRESSING MEPILEX W/AG #498450 272 RC inpatient 128.8 64.4 IMA of Louisiana Commercial PPO 109.48 percent of total billed charges 64.4 109.48 Inpatient Reimbursement at 85% of Billed Charges DRESSING MEPILEX W/AG #498450 272 RC outpatient 128.8 103.04 IMA of Louisiana Commercial PPO 109.48 percent of total billed charges 70.84 109.48 Reimbursement at 85% of billed charges DRESSING MEPILEX W/AG #498450 272 RC outpatient 128.8 103.04 Aetna Commercial PPO 70.84 percent of total billed charges 70.84 109.48 55 of billed Charges EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC inpatient 560 280 BCBS Louisiana PPO 280 percent of total billed charges 280 476 50% of Eligible Charges EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC outpatient 560 448 BCBS Louisiana PPO 448 percent of total billed charges 308 476 80% of billed charge EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC outpatient 560 448 Cigna Commercial PPO 308 percent of total billed charges 308 476 55% of Billed Charges EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC inpatient 560 280 IMA of Louisiana Commercial PPO 476 percent of total billed charges 280 476 Inpatient Reimbursement at 85% of Billed Charges EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC outpatient 560 448 IMA of Louisiana Commercial PPO 476 percent of total billed charges 308 476 Reimbursement at 85% of billed charges EXTRACTOR STRIPPED SCREW 03MM CANNULATED 272 RC outpatient 560 448 Aetna Commercial PPO 308 percent of total billed charges 308 476 55 of billed Charges QUEASE EASE 270 RC inpatient 24.89 12.45 BCBS Louisiana PPO 12.45 percent of total billed charges 12.45 21.16 50% of Eligible Charges QUEASE EASE 270 RC outpatient 24.89 19.91 BCBS Louisiana PPO 19.91 percent of total billed charges 13.69 21.16 80% of billed charge QUEASE EASE 270 RC outpatient 24.89 19.91 Cigna Commercial PPO 13.69 percent of total billed charges 13.69 21.16 55% of Billed Charges QUEASE EASE 270 RC inpatient 24.89 12.45 IMA of Louisiana Commercial PPO 21.16 percent of total billed charges 12.45 21.16 Inpatient Reimbursement at 85% of Billed Charges QUEASE EASE 270 RC outpatient 24.89 19.91 IMA of Louisiana Commercial PPO 21.16 percent of total billed charges 13.69 21.16 Reimbursement at 85% of billed charges QUEASE EASE 270 RC outpatient 24.89 19.91 Aetna Commercial PPO 13.69 percent of total billed charges 13.69 21.16 55 of billed Charges SUTURE 0 VICRYL #JJ41G 272 RC inpatient 48.59 24.3 BCBS Louisiana PPO 24.3 percent of total billed charges 24.3 41.3 50% of Eligible Charges SUTURE 0 VICRYL #JJ41G 272 RC outpatient 48.59 38.87 BCBS Louisiana PPO 38.87 percent of total billed charges 26.72 41.3 80% of billed charge SUTURE 0 VICRYL #JJ41G 272 RC outpatient 48.59 38.87 Cigna Commercial PPO 26.72 percent of total billed charges 26.72 41.3 55% of Billed Charges SUTURE 0 VICRYL #JJ41G 272 RC inpatient 48.59 24.3 IMA of Louisiana Commercial PPO 41.3 percent of total billed charges 24.3 41.3 Inpatient Reimbursement at 85% of Billed Charges SUTURE 0 VICRYL #JJ41G 272 RC outpatient 48.59 38.87 IMA of Louisiana Commercial PPO 41.3 percent of total billed charges 26.72 41.3 Reimbursement at 85% of billed charges SUTURE 0 VICRYL #JJ41G 272 RC outpatient 48.59 38.87 Aetna Commercial PPO 26.72 percent of total billed charges 26.72 41.3 55 of billed Charges DISTRACTION PIN 16MM 272 RC inpatient 562.5 281.25 BCBS Louisiana PPO 281.25 percent of total billed charges 281.25 478.13 50% of Eligible Charges DISTRACTION PIN 16MM 272 RC outpatient 562.5 450 BCBS Louisiana PPO 450 percent of total billed charges 309.38 478.13 80% of billed charge DISTRACTION PIN 16MM 272 RC outpatient 562.5 450 Cigna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55% of Billed Charges DISTRACTION PIN 16MM 272 RC inpatient 562.5 281.25 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 281.25 478.13 Inpatient Reimbursement at 85% of Billed Charges DISTRACTION PIN 16MM 272 RC outpatient 562.5 450 IMA of Louisiana Commercial PPO 478.13 percent of total billed charges 309.38 478.13 Reimbursement at 85% of billed charges DISTRACTION PIN 16MM 272 RC outpatient 562.5 450 Aetna Commercial PPO 309.38 percent of total billed charges 309.38 478.13 55 of billed Charges SUTURE SILK 3-0 SH #C013D 272 RC inpatient 380.28 190.14 BCBS Louisiana PPO 190.14 percent of total billed charges 190.14 323.24 50% of Eligible Charges SUTURE SILK 3-0 SH #C013D 272 RC outpatient 380.28 304.22 BCBS Louisiana PPO 304.22 percent of total billed charges 209.15 323.24 80% of billed charge SUTURE SILK 3-0 SH #C013D 272 RC outpatient 380.28 304.22 Cigna Commercial PPO 209.15 percent of total billed charges 209.15 323.24 55% of Billed Charges SUTURE SILK 3-0 SH #C013D 272 RC inpatient 380.28 190.14 IMA of Louisiana Commercial PPO 323.24 percent of total billed charges 190.14 323.24 Inpatient Reimbursement at 85% of Billed Charges SUTURE SILK 3-0 SH #C013D 272 RC outpatient 380.28 304.22 IMA of Louisiana Commercial PPO 323.24 percent of total billed charges 209.15 323.24 Reimbursement at 85% of billed charges SUTURE SILK 3-0 SH #C013D 272 RC outpatient 380.28 304.22 Aetna Commercial PPO 209.15 percent of total billed charges 209.15 323.24 55 of billed Charges GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC inpatient 464.49 232.25 BCBS Louisiana PPO 232.25 percent of total billed charges 232.25 394.82 50% of Eligible Charges GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC outpatient 464.49 371.59 BCBS Louisiana PPO 371.59 percent of total billed charges 255.47 394.82 80% of billed charge GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC outpatient 464.49 371.59 Cigna Commercial PPO 255.47 percent of total billed charges 255.47 394.82 55% of Billed Charges GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC inpatient 464.49 232.25 IMA of Louisiana Commercial PPO 394.82 percent of total billed charges 232.25 394.82 Inpatient Reimbursement at 85% of Billed Charges GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC outpatient 464.49 371.59 IMA of Louisiana Commercial PPO 394.82 percent of total billed charges 255.47 394.82 Reimbursement at 85% of billed charges GLIDEWIRE STRAIGHT REGULAR - TERUMO 272 RC outpatient 464.49 371.59 Aetna Commercial PPO 255.47 percent of total billed charges 255.47 394.82 55 of billed Charges GLOVE LINER FOR LOBRANO 272 RC inpatient 570.28 285.14 BCBS Louisiana PPO 285.14 percent of total billed charges 285.14 484.74 50% of Eligible Charges GLOVE LINER FOR LOBRANO 272 RC outpatient 570.28 456.22 BCBS Louisiana PPO 456.22 percent of total billed charges 313.65 484.74 80% of billed charge GLOVE LINER FOR LOBRANO 272 RC outpatient 570.28 456.22 Cigna Commercial PPO 313.65 percent of total billed charges 313.65 484.74 55% of Billed Charges GLOVE LINER FOR LOBRANO 272 RC inpatient 570.28 285.14 IMA of Louisiana Commercial PPO 484.74 percent of total billed charges 285.14 484.74 Inpatient Reimbursement at 85% of Billed Charges GLOVE LINER FOR LOBRANO 272 RC outpatient 570.28 456.22 IMA of Louisiana Commercial PPO 484.74 percent of total billed charges 313.65 484.74 Reimbursement at 85% of billed charges GLOVE LINER FOR LOBRANO 272 RC outpatient 570.28 456.22 Aetna Commercial PPO 313.65 percent of total billed charges 313.65 484.74 55 of billed Charges OR SERVICES LEVEL 6 360 RC inpatient 6000 3000 BCBS Louisiana PPO 3000 percent of total billed charges 3000 5100 50% of Eligible Charges OR SERVICES LEVEL 6 360 RC outpatient 6000 4800 BCBS Louisiana PPO 4800 percent of total billed charges 3300 5100 80% of billed charge OR SERVICES LEVEL 6 360 RC outpatient 6000 4800 Cigna Commercial PPO 3300 percent of total billed charges 3300 5100 55% of Billed Charges OR SERVICES LEVEL 6 360 RC inpatient 6000 3000 IMA of Louisiana Commercial PPO 5100 percent of total billed charges 3000 5100 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 6 360 RC outpatient 6000 4800 IMA of Louisiana Commercial PPO 5100 percent of total billed charges 3300 5100 Reimbursement at 85% of billed charges OR SERVICES LEVEL 6 360 RC outpatient 6000 4800 Aetna Commercial PPO 3300 percent of total billed charges 3300 5100 55 of billed Charges OR SERVICES LEVEL 7 360 RC inpatient 9500 4750 BCBS Louisiana PPO 4750 percent of total billed charges 4750 8075 50% of Eligible Charges OR SERVICES LEVEL 7 360 RC outpatient 9500 7600 BCBS Louisiana PPO 7600 percent of total billed charges 5225 8075 80% of billed charge OR SERVICES LEVEL 7 360 RC outpatient 9500 7600 Cigna Commercial PPO 5225 percent of total billed charges 5225 8075 55% of Billed Charges OR SERVICES LEVEL 7 360 RC inpatient 9500 4750 IMA of Louisiana Commercial PPO 8075 percent of total billed charges 4750 8075 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 7 360 RC outpatient 9500 7600 IMA of Louisiana Commercial PPO 8075 percent of total billed charges 5225 8075 Reimbursement at 85% of billed charges OR SERVICES LEVEL 7 360 RC outpatient 9500 7600 Aetna Commercial PPO 5225 percent of total billed charges 5225 8075 55 of billed Charges OR SERVICES LEVEL 14 360 RC inpatient 60000 30000 BCBS Louisiana PPO 30000 percent of total billed charges 30000 51000 50% of Eligible Charges OR SERVICES LEVEL 14 360 RC outpatient 60000 48000 BCBS Louisiana PPO 48000 percent of total billed charges 33000 51000 80% of billed charge OR SERVICES LEVEL 14 360 RC outpatient 60000 48000 Cigna Commercial PPO 33000 percent of total billed charges 33000 51000 55% of Billed Charges OR SERVICES LEVEL 14 360 RC inpatient 60000 30000 IMA of Louisiana Commercial PPO 51000 percent of total billed charges 30000 51000 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES LEVEL 14 360 RC outpatient 60000 48000 IMA of Louisiana Commercial PPO 51000 percent of total billed charges 33000 51000 Reimbursement at 85% of billed charges OR SERVICES LEVEL 14 360 RC outpatient 60000 48000 Aetna Commercial PPO 33000 percent of total billed charges 33000 51000 55 of billed Charges OR SERVICES CHARGE PER MINUTE 360 RC inpatient 110 55 BCBS Louisiana PPO 55 percent of total billed charges 55 93.5 50% of Eligible Charges OR SERVICES CHARGE PER MINUTE 360 RC outpatient 110 88 BCBS Louisiana PPO 88 percent of total billed charges 60.5 93.5 80% of billed charge OR SERVICES CHARGE PER MINUTE 360 RC outpatient 110 88 Cigna Commercial PPO 60.5 percent of total billed charges 60.5 93.5 55% of Billed Charges OR SERVICES CHARGE PER MINUTE 360 RC inpatient 110 55 IMA of Louisiana Commercial PPO 93.5 percent of total billed charges 55 93.5 Inpatient Reimbursement at 85% of Billed Charges OR SERVICES CHARGE PER MINUTE 360 RC outpatient 110 88 IMA of Louisiana Commercial PPO 93.5 percent of total billed charges 60.5 93.5 Reimbursement at 85% of billed charges OR SERVICES CHARGE PER MINUTE 360 RC outpatient 110 88 Aetna Commercial PPO 60.5 percent of total billed charges 60.5 93.5 55 of billed Charges PROC ROOM SERVICES 02 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges PROC ROOM SERVICES 02 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 2214.44 3422.31 80% of billed charge PROC ROOM SERVICES 02 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 2214.44 3422.31 55% of Billed Charges PROC ROOM SERVICES 02 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 02 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2214.44 3422.31 Reimbursement at 85% of billed charges PROC ROOM SERVICES 02 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 2214.44 percent of total billed charges 2214.44 3422.31 55 of billed Charges PROC ROOM SERVICES 13 360 RC inpatient 2643 1321.5 BCBS Louisiana PPO 1321.5 percent of total billed charges 1321.5 2246.55 50% of Eligible Charges PROC ROOM SERVICES 13 360 RC outpatient 2643 2114.4 BCBS Louisiana PPO 2114.4 percent of total billed charges 1453.65 2246.55 80% of billed charge PROC ROOM SERVICES 13 360 RC outpatient 2643 2114.4 Cigna Commercial PPO 1453.65 percent of total billed charges 1453.65 2246.55 55% of Billed Charges PROC ROOM SERVICES 13 360 RC inpatient 2643 1321.5 IMA of Louisiana Commercial PPO 2246.55 percent of total billed charges 1321.5 2246.55 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 13 360 RC outpatient 2643 2114.4 IMA of Louisiana Commercial PPO 2246.55 percent of total billed charges 1453.65 2246.55 Reimbursement at 85% of billed charges PROC ROOM SERVICES 13 360 RC outpatient 2643 2114.4 Aetna Commercial PPO 1453.65 percent of total billed charges 1453.65 2246.55 55 of billed Charges PROC ROOM SERVICES 18 360 RC inpatient 3153 1576.5 BCBS Louisiana PPO 1576.5 percent of total billed charges 1576.5 2680.05 50% of Eligible Charges PROC ROOM SERVICES 18 360 RC outpatient 3153 2522.4 BCBS Louisiana PPO 2522.4 percent of total billed charges 1734.15 2680.05 80% of billed charge PROC ROOM SERVICES 18 360 RC outpatient 3153 2522.4 Cigna Commercial PPO 1734.15 percent of total billed charges 1734.15 2680.05 55% of Billed Charges PROC ROOM SERVICES 18 360 RC inpatient 3153 1576.5 IMA of Louisiana Commercial PPO 2680.05 percent of total billed charges 1576.5 2680.05 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 18 360 RC outpatient 3153 2522.4 IMA of Louisiana Commercial PPO 2680.05 percent of total billed charges 1734.15 2680.05 Reimbursement at 85% of billed charges PROC ROOM SERVICES 18 360 RC outpatient 3153 2522.4 Aetna Commercial PPO 1734.15 percent of total billed charges 1734.15 2680.05 55 of billed Charges PROC ROOM SERVICES 21 360 RC inpatient 3569 1784.5 BCBS Louisiana PPO 1784.5 percent of total billed charges 1784.5 3033.65 50% of Eligible Charges PROC ROOM SERVICES 21 360 RC outpatient 3569 2855.2 BCBS Louisiana PPO 2855.2 percent of total billed charges 1962.95 3033.65 80% of billed charge PROC ROOM SERVICES 21 360 RC outpatient 3569 2855.2 Cigna Commercial PPO 1962.95 percent of total billed charges 1962.95 3033.65 55% of Billed Charges PROC ROOM SERVICES 21 360 RC inpatient 3569 1784.5 IMA of Louisiana Commercial PPO 3033.65 percent of total billed charges 1784.5 3033.65 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 21 360 RC outpatient 3569 2855.2 IMA of Louisiana Commercial PPO 3033.65 percent of total billed charges 1962.95 3033.65 Reimbursement at 85% of billed charges PROC ROOM SERVICES 21 360 RC outpatient 3569 2855.2 Aetna Commercial PPO 1962.95 percent of total billed charges 1962.95 3033.65 55 of billed Charges PROC ROOM SERVICES 27 360 RC inpatient 5883 2941.5 BCBS Louisiana PPO 2941.5 percent of total billed charges 2941.5 5000.55 50% of Eligible Charges PROC ROOM SERVICES 27 360 RC outpatient 5883 4706.4 BCBS Louisiana PPO 4706.4 percent of total billed charges 3235.65 5000.55 80% of billed charge PROC ROOM SERVICES 27 360 RC outpatient 5883 4706.4 Cigna Commercial PPO 3235.65 percent of total billed charges 3235.65 5000.55 55% of Billed Charges PROC ROOM SERVICES 27 360 RC inpatient 5883 2941.5 IMA of Louisiana Commercial PPO 5000.55 percent of total billed charges 2941.5 5000.55 Inpatient Reimbursement at 85% of Billed Charges PROC ROOM SERVICES 27 360 RC outpatient 5883 4706.4 IMA of Louisiana Commercial PPO 5000.55 percent of total billed charges 3235.65 5000.55 Reimbursement at 85% of billed charges PROC ROOM SERVICES 27 360 RC outpatient 5883 4706.4 Aetna Commercial PPO 3235.65 percent of total billed charges 3235.65 5000.55 55 of billed Charges REC ROOM 5.0 HR 710 RC inpatient 5250 2625 BCBS Louisiana PPO 2625 percent of total billed charges 2625 4462.5 50% of Eligible Charges REC ROOM 5.0 HR 710 RC outpatient 5250 4200 BCBS Louisiana PPO 4200 percent of total billed charges 2887.5 4462.5 80% of billed charge REC ROOM 5.0 HR 710 RC outpatient 5250 4200 Cigna Commercial PPO 2887.5 percent of total billed charges 2887.5 4462.5 55% of Billed Charges REC ROOM 5.0 HR 710 RC inpatient 5250 2625 IMA of Louisiana Commercial PPO 4462.5 percent of total billed charges 2625 4462.5 Inpatient Reimbursement at 85% of Billed Charges REC ROOM 5.0 HR 710 RC outpatient 5250 4200 IMA of Louisiana Commercial PPO 4462.5 percent of total billed charges 2887.5 4462.5 Reimbursement at 85% of billed charges REC ROOM 5.0 HR 710 RC outpatient 5250 4200 Aetna Commercial PPO 2887.5 percent of total billed charges 2887.5 4462.5 55 of billed Charges ALKALINE PHOSPHATES 84075 CPT 300 RC inpatient 15.98 7.99 BCBS Louisiana PPO 7.99 percent of total billed charges 7.99 13.58 50% of Eligible Charges ALKALINE PHOSPHATES 84075 CPT 300 RC outpatient 15.98 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 8.79 16.92 70% of billed charges ALKALINE PHOSPHATES 84075 CPT 300 RC outpatient 15.98 11.19 Cigna Commercial PPO 8.79 percent of total billed charges 8.79 16.92 55% of Billed Charges ALKALINE PHOSPHATES 84075 CPT 300 RC inpatient 15.98 7.99 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 7.99 13.58 Inpatient Reimbursement at 85% of Billed Charges ALKALINE PHOSPHATES 84075 CPT 300 RC outpatient 15.98 11.19 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 8.79 16.92 Reimbursement at 85% of billed charges ALKALINE PHOSPHATES 84075 CPT 300 RC outpatient 15.98 11.19 Aetna Commercial PPO 16.92 fee schedule 8.79 16.92 200% Of Aetna Market Fee Schedule Hospital Technical Rate CALCIUM 82310 CPT 300 RC inpatient 15.93 7.97 BCBS Louisiana PPO 7.97 percent of total billed charges 7.97 13.54 50% of Eligible Charges CALCIUM 82310 CPT 300 RC outpatient 15.93 11.15 BCBS Louisiana PPO 11.15 percent of total billed charges 8.76 16.88 70% of billed charges CALCIUM 82310 CPT 300 RC outpatient 15.93 11.15 Cigna Commercial PPO 8.76 percent of total billed charges 8.76 16.88 55% of Billed Charges CALCIUM 82310 CPT 300 RC inpatient 15.93 7.97 IMA of Louisiana Commercial PPO 13.54 percent of total billed charges 7.97 13.54 Inpatient Reimbursement at 85% of Billed Charges CALCIUM 82310 CPT 300 RC outpatient 15.93 11.15 IMA of Louisiana Commercial PPO 13.54 percent of total billed charges 8.76 16.88 Reimbursement at 85% of billed charges CALCIUM 82310 CPT 300 RC outpatient 15.93 11.15 Aetna Commercial PPO 16.88 fee schedule 8.76 16.88 200% Of Aetna Market Fee Schedule Hospital Technical Rate CULTURE AFB 87116 CPT 300 RC inpatient 33.35 16.68 BCBS Louisiana PPO 16.68 percent of total billed charges 16.68 28.35 50% of Eligible Charges CULTURE AFB 87116 CPT 300 RC outpatient 33.35 23.35 BCBS Louisiana PPO 23.35 percent of total billed charges 18.34 35.3 70% of billed charges CULTURE AFB 87116 CPT 300 RC outpatient 33.35 23.35 Cigna Commercial PPO 18.34 percent of total billed charges 18.34 35.3 55% of Billed Charges CULTURE AFB 87116 CPT 300 RC inpatient 33.35 16.68 IMA of Louisiana Commercial PPO 28.35 percent of total billed charges 16.68 28.35 Inpatient Reimbursement at 85% of Billed Charges CULTURE AFB 87116 CPT 300 RC outpatient 33.35 23.35 IMA of Louisiana Commercial PPO 28.35 percent of total billed charges 18.34 35.3 Reimbursement at 85% of billed charges CULTURE AFB 87116 CPT 300 RC outpatient 33.35 23.35 Aetna Commercial PPO 35.3 fee schedule 18.34 35.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate PLATELET COUNT 85049 CPT 300 RC inpatient 13.83 6.92 BCBS Louisiana PPO 6.92 percent of total billed charges 6.92 11.76 50% of Eligible Charges PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 BCBS Louisiana PPO 9.68 percent of total billed charges 7.61 13.46 70% of billed charges PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 Cigna Commercial PPO 7.61 percent of total billed charges 7.61 13.46 55% of Billed Charges PLATELET COUNT 85049 CPT 300 RC inpatient 13.83 6.92 IMA of Louisiana Commercial PPO 11.76 percent of total billed charges 6.92 11.76 Inpatient Reimbursement at 85% of Billed Charges PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 IMA of Louisiana Commercial PPO 11.76 percent of total billed charges 7.61 13.46 Reimbursement at 85% of billed charges PLATELET COUNT 85049 CPT 300 RC outpatient 13.83 9.68 Aetna Commercial PPO 13.46 fee schedule 7.61 13.46 200% Of Aetna Market Fee Schedule Hospital Technical Rate URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC inpatient 6.93 3.47 BCBS Louisiana PPO 3.47 percent of total billed charges 3.47 5.89 50% of Eligible Charges URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC outpatient 6.93 4.85 BCBS Louisiana PPO 4.85 percent of total billed charges 3.81 7.34 70% of billed charges URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC outpatient 6.93 4.85 Cigna Commercial PPO 3.81 percent of total billed charges 3.81 7.34 55% of Billed Charges URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC inpatient 6.93 3.47 IMA of Louisiana Commercial PPO 5.89 percent of total billed charges 3.47 5.89 Inpatient Reimbursement at 85% of Billed Charges URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC outpatient 6.93 4.85 IMA of Louisiana Commercial PPO 5.89 percent of total billed charges 3.81 7.34 Reimbursement at 85% of billed charges URINALYSIS w/ CULTURE IF INDICATED 81003 CPT 300 RC outpatient 6.93 4.85 Aetna Commercial PPO 7.34 fee schedule 3.81 7.34 200% Of Aetna Market Fee Schedule Hospital Technical Rate PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC inpatient 66.3 33.15 BCBS Louisiana PPO 33.15 percent of total billed charges 33.15 56.36 50% of Eligible Charges PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC outpatient 66.3 46.41 BCBS Louisiana PPO 46.41 percent of total billed charges 36.47 70.24 70% of billed charges PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC outpatient 66.3 46.41 Cigna Commercial PPO 36.47 percent of total billed charges 36.47 70.24 55% of Billed Charges PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC inpatient 66.3 33.15 IMA of Louisiana Commercial PPO 56.36 percent of total billed charges 33.15 56.36 Inpatient Reimbursement at 85% of Billed Charges PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC outpatient 66.3 46.41 IMA of Louisiana Commercial PPO 56.36 percent of total billed charges 36.47 70.24 Reimbursement at 85% of billed charges PLATELET FUNCTION ANALYSIS 85576 CPT 300 RC outpatient 66.3 46.41 Aetna Commercial PPO 70.24 fee schedule 36.47 70.24 200% Of Aetna Market Fee Schedule Hospital Technical Rate EKG OR ECG 93005 CPT 730 RC inpatient 139.9 69.95 BCBS Louisiana PPO 69.95 percent of total billed charges 69.95 118.92 50% of Eligible Charges EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 BCBS Louisiana PPO 111.92 percent of total billed charges 10.83 118.92 80% of billed charge EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 Cigna Commercial PPO 76.95 percent of total billed charges 10.83 118.92 55% of Billed Charges EKG OR ECG 93005 CPT 730 RC inpatient 139.9 69.95 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 69.95 118.92 Inpatient Reimbursement at 85% of Billed Charges EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 IMA of Louisiana Commercial PPO 118.92 percent of total billed charges 10.83 118.92 Reimbursement at 85% of billed charges EKG OR ECG 93005 CPT 730 RC outpatient 139.9 111.92 Aetna Commercial PPO 10.83 fee schedule 10.83 118.92 100 of Aetna Market Fee Schedule IRON / TIBC 83550 CPT 301 RC inpatient 26.98 13.49 BCBS Louisiana PPO 13.49 percent of total billed charges 13.49 22.93 50% of Eligible Charges IRON / TIBC 83550 CPT 301 RC outpatient 26.98 18.89 BCBS Louisiana PPO 18.89 percent of total billed charges 14.84 28.58 70% of billed charges IRON / TIBC 83550 CPT 301 RC outpatient 26.98 18.89 Cigna Commercial PPO 14.84 percent of total billed charges 14.84 28.58 55% of Billed Charges IRON / TIBC 83550 CPT 301 RC inpatient 26.98 13.49 IMA of Louisiana Commercial PPO 22.93 percent of total billed charges 13.49 22.93 Inpatient Reimbursement at 85% of Billed Charges IRON / TIBC 83550 CPT 301 RC outpatient 26.98 18.89 IMA of Louisiana Commercial PPO 22.93 percent of total billed charges 14.84 28.58 Reimbursement at 85% of billed charges IRON / TIBC 83550 CPT 301 RC outpatient 26.98 18.89 Aetna Commercial PPO 28.58 fee schedule 14.84 28.58 200% Of Aetna Market Fee Schedule Hospital Technical Rate CKMB 82553 CPT 301 RC inpatient 35.65 17.83 BCBS Louisiana PPO 17.83 percent of total billed charges 17.83 30.3 50% of Eligible Charges CKMB 82553 CPT 301 RC outpatient 35.65 24.96 BCBS Louisiana PPO 24.96 percent of total billed charges 19.61 37.76 70% of billed charges CKMB 82553 CPT 301 RC outpatient 35.65 24.96 Cigna Commercial PPO 19.61 percent of total billed charges 19.61 37.76 55% of Billed Charges CKMB 82553 CPT 301 RC inpatient 35.65 17.83 IMA of Louisiana Commercial PPO 30.3 percent of total billed charges 17.83 30.3 Inpatient Reimbursement at 85% of Billed Charges CKMB 82553 CPT 301 RC outpatient 35.65 24.96 IMA of Louisiana Commercial PPO 30.3 percent of total billed charges 19.61 37.76 Reimbursement at 85% of billed charges CKMB 82553 CPT 301 RC outpatient 35.65 24.96 Aetna Commercial PPO 37.76 fee schedule 19.61 37.76 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_PTT 85730 CPT 300 RC inpatient 18.55 9.28 BCBS Louisiana PPO 9.28 percent of total billed charges 9.28 15.77 50% of Eligible Charges prad_PTT 85730 CPT 300 RC outpatient 18.55 12.99 BCBS Louisiana PPO 12.99 percent of total billed charges 10.2 19.64 70% of billed charges prad_PTT 85730 CPT 300 RC outpatient 18.55 12.99 Cigna Commercial PPO 10.2 percent of total billed charges 10.2 19.64 55% of Billed Charges prad_PTT 85730 CPT 300 RC inpatient 18.55 9.28 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 9.28 15.77 Inpatient Reimbursement at 85% of Billed Charges prad_PTT 85730 CPT 300 RC outpatient 18.55 12.99 IMA of Louisiana Commercial PPO 15.77 percent of total billed charges 10.2 19.64 Reimbursement at 85% of billed charges prad_PTT 85730 CPT 300 RC outpatient 18.55 12.99 Aetna Commercial PPO 19.64 fee schedule 10.2 19.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate METAL SENSITIVITY TEST 86353 CPT 300 RC inpatient 151.33 75.67 BCBS Louisiana PPO 75.67 percent of total billed charges 75.67 128.63 50% of Eligible Charges METAL SENSITIVITY TEST 86353 CPT 300 RC outpatient 151.33 105.93 BCBS Louisiana PPO 105.93 percent of total billed charges 83.23 160.3 70% of billed charges METAL SENSITIVITY TEST 86353 CPT 300 RC outpatient 151.33 105.93 Cigna Commercial PPO 83.23 percent of total billed charges 83.23 160.3 55% of Billed Charges METAL SENSITIVITY TEST 86353 CPT 300 RC inpatient 151.33 75.67 IMA of Louisiana Commercial PPO 128.63 percent of total billed charges 75.67 128.63 Inpatient Reimbursement at 85% of Billed Charges METAL SENSITIVITY TEST 86353 CPT 300 RC outpatient 151.33 105.93 IMA of Louisiana Commercial PPO 128.63 percent of total billed charges 83.23 160.3 Reimbursement at 85% of billed charges METAL SENSITIVITY TEST 86353 CPT 300 RC outpatient 151.33 105.93 Aetna Commercial PPO 160.3 fee schedule 83.23 160.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_BMP 80048 CPT 300 RC inpatient 26.1 13.05 BCBS Louisiana PPO 13.05 percent of total billed charges 13.05 22.19 50% of Eligible Charges inpt3_BMP 80048 CPT 300 RC outpatient 26.1 18.27 BCBS Louisiana PPO 18.27 percent of total billed charges 14.36 27.64 70% of billed charges inpt3_BMP 80048 CPT 300 RC outpatient 26.1 18.27 Cigna Commercial PPO 14.36 percent of total billed charges 14.36 27.64 55% of Billed Charges inpt3_BMP 80048 CPT 300 RC inpatient 26.1 13.05 IMA of Louisiana Commercial PPO 22.19 percent of total billed charges 13.05 22.19 Inpatient Reimbursement at 85% of Billed Charges inpt3_BMP 80048 CPT 300 RC outpatient 26.1 18.27 IMA of Louisiana Commercial PPO 22.19 percent of total billed charges 14.36 27.64 Reimbursement at 85% of billed charges inpt3_BMP 80048 CPT 300 RC outpatient 26.1 18.27 Aetna Commercial PPO 27.64 fee schedule 14.36 27.64 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC inpatient 41.8 20.9 BCBS Louisiana PPO 20.9 percent of total billed charges 20.9 35.53 50% of Eligible Charges inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC outpatient 41.8 29.26 BCBS Louisiana PPO 29.26 percent of total billed charges 22.99 44.3 70% of billed charges inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC outpatient 41.8 29.26 Cigna Commercial PPO 22.99 percent of total billed charges 22.99 44.3 55% of Billed Charges inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC inpatient 41.8 20.9 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 20.9 35.53 Inpatient Reimbursement at 85% of Billed Charges inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC outpatient 41.8 29.26 IMA of Louisiana Commercial PPO 35.53 percent of total billed charges 22.99 44.3 Reimbursement at 85% of billed charges inpt3_VANCOMYCIN PEAK 80202 CPT 300 RC outpatient 41.8 29.26 Aetna Commercial PPO 44.3 fee schedule 22.99 44.3 200% Of Aetna Market Fee Schedule Hospital Technical Rate inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 BCBS Louisiana PPO 7.99 percent of total billed charges 7.99 13.58 50% of Eligible Charges inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 8.79 16.92 70% of billed charges inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Cigna Commercial PPO 8.79 percent of total billed charges 8.79 16.92 55% of Billed Charges inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 7.99 13.58 Inpatient Reimbursement at 85% of Billed Charges inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 8.79 16.92 Reimbursement at 85% of billed charges inpt3_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Aetna Commercial PPO 16.92 fee schedule 8.79 16.92 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC inpatient 37.3 18.65 BCBS Louisiana PPO 18.65 percent of total billed charges 18.65 31.71 50% of Eligible Charges prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 BCBS Louisiana PPO 26.11 percent of total billed charges 20.52 39.52 70% of billed charges prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 Cigna Commercial PPO 20.52 percent of total billed charges 20.52 39.52 55% of Billed Charges prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC inpatient 37.3 18.65 IMA of Louisiana Commercial PPO 31.71 percent of total billed charges 18.65 31.71 Inpatient Reimbursement at 85% of Billed Charges prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 IMA of Louisiana Commercial PPO 31.71 percent of total billed charges 20.52 39.52 Reimbursement at 85% of billed charges prad_ANTI. NUCLEAR AB SCREEN ONLY (ANA) 86038 CPT 302 RC outpatient 37.3 26.11 Aetna Commercial PPO 39.52 fee schedule 20.52 39.52 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 BCBS Louisiana PPO 7.99 percent of total billed charges 7.99 13.58 50% of Eligible Charges prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 BCBS Louisiana PPO 11.19 percent of total billed charges 8.79 16.92 70% of billed charges prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Cigna Commercial PPO 8.79 percent of total billed charges 8.79 16.92 55% of Billed Charges prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC inpatient 15.98 7.99 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 7.99 13.58 Inpatient Reimbursement at 85% of Billed Charges prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 IMA of Louisiana Commercial PPO 13.58 percent of total billed charges 8.79 16.92 Reimbursement at 85% of billed charges prad_C-REACTIVE PROTEIN QUANT 86140 CPT 300 RC outpatient 15.98 11.19 Aetna Commercial PPO 16.92 fee schedule 8.79 16.92 200% Of Aetna Market Fee Schedule Hospital Technical Rate prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC inpatient 224.53 112.27 BCBS Louisiana PPO 112.27 percent of total billed charges 112.27 190.85 50% of Eligible Charges prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC outpatient 224.53 157.17 BCBS Louisiana PPO 157.17 percent of total billed charges 123.49 237.84 70% of billed charges prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC outpatient 224.53 157.17 Cigna Commercial PPO 123.49 percent of total billed charges 123.49 237.84 55% of Billed Charges prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC inpatient 224.53 112.27 IMA of Louisiana Commercial PPO 190.85 percent of total billed charges 112.27 190.85 Inpatient Reimbursement at 85% of Billed Charges prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC outpatient 224.53 157.17 IMA of Louisiana Commercial PPO 190.85 percent of total billed charges 123.49 237.84 Reimbursement at 85% of billed charges prad_HUMAN LEUKOCYTE ANTIGEN B27 81374 CPT 300 RC outpatient 224.53 157.17 Aetna Commercial PPO 237.84 fee schedule 123.49 237.84 200% Of Aetna Market Fee Schedule Hospital Technical Rate RAPID SARS-CoV-2 86328 CPT 300 RC inpatient 289.16 144.58 BCBS Louisiana PPO 144.58 percent of total billed charges 144.58 245.79 50% of Eligible Charges RAPID SARS-CoV-2 86328 CPT 300 RC outpatient 289.16 202.41 BCBS Louisiana PPO 202.41 percent of total billed charges 159.04 400 70% of billed charges RAPID SARS-CoV-2 86328 CPT 300 RC outpatient 289.16 202.41 Cigna Commercial PPO 159.04 percent of total billed charges 159.04 400 55% of Billed Charges RAPID SARS-CoV-2 86328 CPT 300 RC inpatient 289.16 144.58 IMA of Louisiana Commercial PPO 245.79 percent of total billed charges 144.58 245.79 Inpatient Reimbursement at 85% of Billed Charges RAPID SARS-CoV-2 86328 CPT 300 RC outpatient 289.16 202.41 IMA of Louisiana Commercial PPO 245.79 percent of total billed charges 159.04 400 Reimbursement at 85% of billed charges RAPID SARS-CoV-2 86328 CPT 300 RC outpatient 289.16 202.41 Aetna Commercial PPO 400 fee schedule 159.04 400 200% Of Aetna Market Fee Schedule Hospital Technical Rate XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT ANKLE COMPLETE 73610 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges XRAY DX FLUOROSCPY MORE 77001 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT inpatient 205 102.5 BCBS Louisiana PPO 102.5 percent of total billed charges 102.5 174.25 50% of Eligible Charges XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT outpatient 205 143.5 BCBS Louisiana PPO 143.5 percent of total billed charges 112.75 700 70% of billed charges XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT outpatient 205 143.5 Cigna Commercial PPO 112.75 percent of total billed charges 112.75 700 55% of Billed Charges XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT inpatient 205 102.5 IMA of Louisiana Commercial PPO 174.25 percent of total billed charges 102.5 174.25 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT outpatient 205 143.5 IMA of Louisiana Commercial PPO 174.25 percent of total billed charges 112.75 700 Reimbursement at 85% of billed charges XRAY DX RT HIP 1 VIEW 73501 CPT 320 RC RT outpatient 205 143.5 Aetna Commercial PPO 700 case rate 112.75 700 700 Per Code Per DOS Paid In Addition XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT WRIST AP&LAT 73100 CPT 320 RC RT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT FEMUR 73552 CPT 320 RC LT inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX LT FEMUR 73552 CPT 320 RC LT outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX LT FEMUR 73552 CPT 320 RC LT outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX LT FEMUR 73552 CPT 320 RC LT inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT FEMUR 73552 CPT 320 RC LT outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX LT FEMUR 73552 CPT 320 RC LT outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX LT SHOULDER 73020 CPT 320 RC LT inpatient 90.45 45.23 BCBS Louisiana PPO 45.23 percent of total billed charges 45.23 76.88 50% of Eligible Charges XRAY DX LT SHOULDER 73020 CPT 320 RC LT outpatient 90.45 63.32 BCBS Louisiana PPO 63.32 percent of total billed charges 49.75 700 70% of billed charges XRAY DX LT SHOULDER 73020 CPT 320 RC LT outpatient 90.45 63.32 Cigna Commercial PPO 49.75 percent of total billed charges 49.75 700 55% of Billed Charges XRAY DX LT SHOULDER 73020 CPT 320 RC LT inpatient 90.45 45.23 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 45.23 76.88 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT SHOULDER 73020 CPT 320 RC LT outpatient 90.45 63.32 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 49.75 700 Reimbursement at 85% of billed charges XRAY DX LT SHOULDER 73020 CPT 320 RC LT outpatient 90.45 63.32 Aetna Commercial PPO 700 case rate 49.75 700 700 Per Code Per DOS Paid In Addition MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 406.55 750 70% of billed charges MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC outpatient 580.78 406.55 Cigna Commercial PPO 750 other 406.55 750 $750 Per Scan MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 406.55 750 Reimbursement at 85% of billed charges MRI LUMBAR SPINE WITHOUT 72148 CPT 612 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 406.55 750 700 Per Code Per DOS Paid In Addition CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges CT NECK SPINE WITHOUT DYE 72125 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges CT LUMBAR SPINE WITHOUT DYE 72131 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 200.31 700 70% of billed charges CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC outpatient 286.15 200.31 Cigna Commercial PPO 700 other 200.31 700 $700 Per Visit CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 200.31 700 Reimbursement at 85% of billed charges CT SCAN OF THORAX (CHEST) W/O CONTRAST 71250 CPT 350 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 200.31 700 700 Per Code Per DOS Paid In Addition X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC inpatient 67.6 33.8 BCBS Louisiana PPO 33.8 percent of total billed charges 33.8 57.46 50% of Eligible Charges X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC outpatient 67.6 47.32 BCBS Louisiana PPO 47.32 percent of total billed charges 37.18 700 70% of billed charges X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC outpatient 67.6 47.32 Cigna Commercial PPO 37.18 percent of total billed charges 37.18 700 55% of Billed Charges X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC inpatient 67.6 33.8 IMA of Louisiana Commercial PPO 57.46 percent of total billed charges 33.8 57.46 Inpatient Reimbursement at 85% of Billed Charges X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC outpatient 67.6 47.32 IMA of Louisiana Commercial PPO 57.46 percent of total billed charges 37.18 700 Reimbursement at 85% of billed charges X-RAY DX HIP 2 VIEW - LEFT 73502 CPT 320 RC outpatient 67.6 47.32 Aetna Commercial PPO 700 case rate 37.18 700 700 Per Code Per DOS Paid In Addition X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges X-RAY SCOLI ELAVUATION 1 VIEW 72081 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METOPROLOL TART 50MG TABLET 250 RC 5107980120 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC inpatient 1 EA 9.22 4.61 BCBS Louisiana PPO 4.61 percent of total billed charges 4.61 7.84 50% of Eligible Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 BCBS Louisiana PPO 7.38 percent of total billed charges 5.07 7.84 80% of billed charge LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 Cigna Commercial PPO 5.07 percent of total billed charges 5.07 7.84 55% of Billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC inpatient 1 EA 9.22 4.61 IMA of Louisiana Commercial PPO 7.84 percent of total billed charges 4.61 7.84 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 5% TRANSDERM PATCH J3490 HCPCS 250 RC 0591352530 NDC outpatient 1 EA 9.22 7.38 IMA of Louisiana Commercial PPO 7.84 percent of total billed charges 5.07 7.84 Reimbursement at 85% of billed charges NASAL SPRAY 250 RC 0904386575 NDC inpatient 1 EA 4.74 2.37 BCBS Louisiana PPO 2.37 percent of total billed charges 2.37 4.03 50% of Eligible Charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 BCBS Louisiana PPO 3.79 percent of total billed charges 2.61 4.03 80% of billed charge NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 Cigna Commercial PPO 2.61 percent of total billed charges 2.61 4.03 55% of Billed Charges NASAL SPRAY 250 RC 0904386575 NDC inpatient 1 EA 4.74 2.37 IMA of Louisiana Commercial PPO 4.03 percent of total billed charges 2.37 4.03 Inpatient Reimbursement at 85% of Billed Charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 IMA of Louisiana Commercial PPO 4.03 percent of total billed charges 2.61 4.03 Reimbursement at 85% of billed charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 Aetna Commercial PPO 2.61 percent of total billed charges 2.61 4.03 55 of billed Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC inpatient 1 EA 445.35 222.68 BCBS Louisiana PPO 222.68 percent of total billed charges 222.68 378.55 50% of Eligible Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 BCBS Louisiana PPO 356.28 percent of total billed charges 244.94 378.55 80% of billed charge PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 Cigna Commercial PPO 244.94 percent of total billed charges 244.94 378.55 55% of Billed Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC inpatient 1 EA 445.35 222.68 IMA of Louisiana Commercial PPO 378.55 percent of total billed charges 222.68 378.55 Inpatient Reimbursement at 85% of Billed Charges PULMICORT INHALER NON-FORMULARY J8499 HCPCS 250 RC 0186091612 NDC outpatient 1 EA 445.35 356.28 IMA of Louisiana Commercial PPO 378.55 percent of total billed charges 244.94 378.55 Reimbursement at 85% of billed charges ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC inpatient 10 ME 12.17 6.09 BCBS Louisiana PPO 6.09 percent of total billed charges 6.09 10.34 50% of Eligible Charges ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC outpatient 10 ME 12.17 9.74 BCBS Louisiana PPO 9.74 percent of total billed charges 6.69 10.34 80% of billed charge ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC outpatient 10 ME 12.17 9.74 Cigna Commercial PPO 6.69 percent of total billed charges 6.69 10.34 55% of Billed Charges ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC inpatient 10 ME 12.17 6.09 IMA of Louisiana Commercial PPO 10.34 percent of total billed charges 6.09 10.34 Inpatient Reimbursement at 85% of Billed Charges ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC outpatient 10 ME 12.17 9.74 IMA of Louisiana Commercial PPO 10.34 percent of total billed charges 6.69 10.34 Reimbursement at 85% of billed charges ESMOLOL 10MG/ML 10ML VIAL 260 RC 5515019410 NDC outpatient 10 ME 12.17 9.74 Aetna Commercial PPO 6.69 percent of total billed charges 6.69 10.34 55 of billed Charges METHYLPREDNISOLONE 80MG/ML 1ML INJ J1040 HCPCS 250 RC 0009347503 NDC inpatient 80 ME 110.58 55.29 BCBS Louisiana PPO 55.29 percent of total billed charges 55.29 93.99 50% of Eligible Charges METHYLPREDNISOLONE 80MG/ML 1ML INJ J1040 HCPCS 250 RC 0009347503 NDC outpatient 80 ME 110.58 88.46 BCBS Louisiana PPO 88.46 percent of total billed charges 60.82 93.99 80% of billed charge METHYLPREDNISOLONE 80MG/ML 1ML INJ J1040 HCPCS 250 RC 0009347503 NDC outpatient 80 ME 110.58 88.46 Cigna Commercial PPO 60.82 percent of total billed charges 60.82 93.99 55% of Billed Charges METHYLPREDNISOLONE 80MG/ML 1ML INJ J1040 HCPCS 250 RC 0009347503 NDC inpatient 80 ME 110.58 55.29 IMA of Louisiana Commercial PPO 93.99 percent of total billed charges 55.29 93.99 Inpatient Reimbursement at 85% of Billed Charges METHYLPREDNISOLONE 80MG/ML 1ML INJ J1040 HCPCS 250 RC 0009347503 NDC outpatient 80 ME 110.58 88.46 IMA of Louisiana Commercial PPO 93.99 percent of total billed charges 60.82 93.99 Reimbursement at 85% of billed charges DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC inpatient 50 ML 106.14 53.07 BCBS Louisiana PPO 53.07 percent of total billed charges 53.07 90.22 50% of Eligible Charges DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC outpatient 50 ML 106.14 84.91 BCBS Louisiana PPO 84.91 percent of total billed charges 58.38 90.22 80% of billed charge DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC outpatient 50 ML 106.14 84.91 Cigna Commercial PPO 58.38 percent of total billed charges 58.38 90.22 55% of Billed Charges DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC inpatient 50 ML 106.14 53.07 IMA of Louisiana Commercial PPO 90.22 percent of total billed charges 53.07 90.22 Inpatient Reimbursement at 85% of Billed Charges DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC outpatient 50 ML 106.14 84.91 IMA of Louisiana Commercial PPO 90.22 percent of total billed charges 58.38 90.22 Reimbursement at 85% of billed charges DEXTROSE 50% 50ML ABOJ SYRG 260 RC 7632933021 NDC outpatient 50 ML 106.14 84.91 Aetna Commercial PPO 58.38 percent of total billed charges 58.38 90.22 55 of billed Charges FLEET ENEMA : 135ML 250 RC 0536741551 NDC inpatient 135 ML 6 3 BCBS Louisiana PPO 3 percent of total billed charges 3 5.1 50% of Eligible Charges FLEET ENEMA : 135ML 250 RC 0536741551 NDC outpatient 135 ML 6 4.8 BCBS Louisiana PPO 4.8 percent of total billed charges 3.3 5.1 80% of billed charge FLEET ENEMA : 135ML 250 RC 0536741551 NDC outpatient 135 ML 6 4.8 Cigna Commercial PPO 3.3 percent of total billed charges 3.3 5.1 55% of Billed Charges FLEET ENEMA : 135ML 250 RC 0536741551 NDC inpatient 135 ML 6 3 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3 5.1 Inpatient Reimbursement at 85% of Billed Charges FLEET ENEMA : 135ML 250 RC 0536741551 NDC outpatient 135 ML 6 4.8 IMA of Louisiana Commercial PPO 5.1 percent of total billed charges 3.3 5.1 Reimbursement at 85% of billed charges FLEET ENEMA : 135ML 250 RC 0536741551 NDC outpatient 135 ML 6 4.8 Aetna Commercial PPO 3.3 percent of total billed charges 3.3 5.1 55 of billed Charges "HEPARIN SODIUM 10,000U/ML 1ML" J1644 HCPCS 250 RC 7128840402 NDC inpatient 1 ML 6.97 3.49 BCBS Louisiana PPO 3.49 percent of total billed charges 3.49 5.92 50% of Eligible Charges "HEPARIN SODIUM 10,000U/ML 1ML" J1644 HCPCS 250 RC 7128840402 NDC outpatient 1 ML 6.97 5.58 BCBS Louisiana PPO 5.58 percent of total billed charges 3.83 5.92 80% of billed charge "HEPARIN SODIUM 10,000U/ML 1ML" J1644 HCPCS 250 RC 7128840402 NDC outpatient 1 ML 6.97 5.58 Cigna Commercial PPO 3.83 percent of total billed charges 3.83 5.92 55% of Billed Charges "HEPARIN SODIUM 10,000U/ML 1ML" J1644 HCPCS 250 RC 7128840402 NDC inpatient 1 ML 6.97 3.49 IMA of Louisiana Commercial PPO 5.92 percent of total billed charges 3.49 5.92 Inpatient Reimbursement at 85% of Billed Charges "HEPARIN SODIUM 10,000U/ML 1ML" J1644 HCPCS 250 RC 7128840402 NDC outpatient 1 ML 6.97 5.58 IMA of Louisiana Commercial PPO 5.92 percent of total billed charges 3.83 5.92 Reimbursement at 85% of billed charges LIDOCAINE 1% 30ML PF J2001 HCPCS 250 RC 6332349226 NDC inpatient 30 ML 16.61 8.31 BCBS Louisiana PPO 8.31 percent of total billed charges 8.31 14.12 50% of Eligible Charges LIDOCAINE 1% 30ML PF J2001 HCPCS 250 RC 6332349226 NDC outpatient 30 ML 16.61 13.29 BCBS Louisiana PPO 13.29 percent of total billed charges 9.14 14.12 80% of billed charge LIDOCAINE 1% 30ML PF J2001 HCPCS 250 RC 6332349226 NDC outpatient 30 ML 16.61 13.29 Cigna Commercial PPO 9.14 percent of total billed charges 9.14 14.12 55% of Billed Charges LIDOCAINE 1% 30ML PF J2001 HCPCS 250 RC 6332349226 NDC inpatient 30 ML 16.61 8.31 IMA of Louisiana Commercial PPO 14.12 percent of total billed charges 8.31 14.12 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE 1% 30ML PF J2001 HCPCS 250 RC 6332349226 NDC outpatient 30 ML 16.61 13.29 IMA of Louisiana Commercial PPO 14.12 percent of total billed charges 9.14 14.12 Reimbursement at 85% of billed charges BUPIVACAINE 0.25% W/EPI 30ML J3490 HCPCS 250 RC 6332346837 NDC inpatient 30 ML 40.32 20.16 BCBS Louisiana PPO 20.16 percent of total billed charges 20.16 34.27 50% of Eligible Charges BUPIVACAINE 0.25% W/EPI 30ML J3490 HCPCS 250 RC 6332346837 NDC outpatient 30 ML 40.32 32.26 BCBS Louisiana PPO 32.26 percent of total billed charges 22.18 34.27 80% of billed charge BUPIVACAINE 0.25% W/EPI 30ML J3490 HCPCS 250 RC 6332346837 NDC outpatient 30 ML 40.32 32.26 Cigna Commercial PPO 22.18 percent of total billed charges 22.18 34.27 55% of Billed Charges BUPIVACAINE 0.25% W/EPI 30ML J3490 HCPCS 250 RC 6332346837 NDC inpatient 30 ML 40.32 20.16 IMA of Louisiana Commercial PPO 34.27 percent of total billed charges 20.16 34.27 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.25% W/EPI 30ML J3490 HCPCS 250 RC 6332346837 NDC outpatient 30 ML 40.32 32.26 IMA of Louisiana Commercial PPO 34.27 percent of total billed charges 22.18 34.27 Reimbursement at 85% of billed charges BUPIVACAINE 0.5% 30ML J3490 HCPCS 250 RC 6332346637 NDC inpatient 30 ML 11.52 5.76 BCBS Louisiana PPO 5.76 percent of total billed charges 5.76 9.79 50% of Eligible Charges BUPIVACAINE 0.5% 30ML J3490 HCPCS 250 RC 6332346637 NDC outpatient 30 ML 11.52 9.22 BCBS Louisiana PPO 9.22 percent of total billed charges 6.34 9.79 80% of billed charge BUPIVACAINE 0.5% 30ML J3490 HCPCS 250 RC 6332346637 NDC outpatient 30 ML 11.52 9.22 Cigna Commercial PPO 6.34 percent of total billed charges 6.34 9.79 55% of Billed Charges BUPIVACAINE 0.5% 30ML J3490 HCPCS 250 RC 6332346637 NDC inpatient 30 ML 11.52 5.76 IMA of Louisiana Commercial PPO 9.79 percent of total billed charges 5.76 9.79 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.5% 30ML J3490 HCPCS 250 RC 6332346637 NDC outpatient 30 ML 11.52 9.22 IMA of Louisiana Commercial PPO 9.79 percent of total billed charges 6.34 9.79 Reimbursement at 85% of billed charges MYLANTA 30ML 250 RC 0121176130 NDC inpatient 30 ML 13.5 6.75 BCBS Louisiana PPO 6.75 percent of total billed charges 6.75 11.48 50% of Eligible Charges MYLANTA 30ML 250 RC 0121176130 NDC outpatient 30 ML 13.5 10.8 BCBS Louisiana PPO 10.8 percent of total billed charges 7.43 11.48 80% of billed charge MYLANTA 30ML 250 RC 0121176130 NDC outpatient 30 ML 13.5 10.8 Cigna Commercial PPO 7.43 percent of total billed charges 7.43 11.48 55% of Billed Charges MYLANTA 30ML 250 RC 0121176130 NDC inpatient 30 ML 13.5 6.75 IMA of Louisiana Commercial PPO 11.48 percent of total billed charges 6.75 11.48 Inpatient Reimbursement at 85% of Billed Charges MYLANTA 30ML 250 RC 0121176130 NDC outpatient 30 ML 13.5 10.8 IMA of Louisiana Commercial PPO 11.48 percent of total billed charges 7.43 11.48 Reimbursement at 85% of billed charges MYLANTA 30ML 250 RC 0121176130 NDC outpatient 30 ML 13.5 10.8 Aetna Commercial PPO 7.43 percent of total billed charges 7.43 11.48 55 of billed Charges ROPIVACAINE 0.5% 30ML J2795 HCPCS 250 RC 6332328635 NDC inpatient 30 ML 26.4 13.2 BCBS Louisiana PPO 13.2 percent of total billed charges 13.2 22.44 50% of Eligible Charges ROPIVACAINE 0.5% 30ML J2795 HCPCS 250 RC 6332328635 NDC outpatient 30 ML 26.4 21.12 BCBS Louisiana PPO 21.12 percent of total billed charges 14.52 22.44 80% of billed charge ROPIVACAINE 0.5% 30ML J2795 HCPCS 250 RC 6332328635 NDC outpatient 30 ML 26.4 21.12 Cigna Commercial PPO 14.52 percent of total billed charges 14.52 22.44 55% of Billed Charges ROPIVACAINE 0.5% 30ML J2795 HCPCS 250 RC 6332328635 NDC inpatient 30 ML 26.4 13.2 IMA of Louisiana Commercial PPO 22.44 percent of total billed charges 13.2 22.44 Inpatient Reimbursement at 85% of Billed Charges ROPIVACAINE 0.5% 30ML J2795 HCPCS 250 RC 6332328635 NDC outpatient 30 ML 26.4 21.12 IMA of Louisiana Commercial PPO 22.44 percent of total billed charges 14.52 22.44 Reimbursement at 85% of billed charges PROMETHAZINE 25MG/ML 1ML INJ. J2550 HCPCS 250 RC 0641092825 NDC inpatient 25 ME 9.97 4.99 BCBS Louisiana PPO 4.99 percent of total billed charges 4.99 8.47 50% of Eligible Charges PROMETHAZINE 25MG/ML 1ML INJ. J2550 HCPCS 250 RC 0641092825 NDC outpatient 25 ME 9.97 7.98 BCBS Louisiana PPO 7.98 percent of total billed charges 5.48 8.47 80% of billed charge PROMETHAZINE 25MG/ML 1ML INJ. J2550 HCPCS 250 RC 0641092825 NDC outpatient 25 ME 9.97 7.98 Cigna Commercial PPO 5.48 percent of total billed charges 5.48 8.47 55% of Billed Charges PROMETHAZINE 25MG/ML 1ML INJ. J2550 HCPCS 250 RC 0641092825 NDC inpatient 25 ME 9.97 4.99 IMA of Louisiana Commercial PPO 8.47 percent of total billed charges 4.99 8.47 Inpatient Reimbursement at 85% of Billed Charges PROMETHAZINE 25MG/ML 1ML INJ. J2550 HCPCS 250 RC 0641092825 NDC outpatient 25 ME 9.97 7.98 IMA of Louisiana Commercial PPO 8.47 percent of total billed charges 5.48 8.47 Reimbursement at 85% of billed charges PROPOFOL 10MG/ML 20ML J2704 HCPCS 636 RC 0409601025 NDC inpatient 10 ME 12.62 6.31 BCBS Louisiana PPO 6.31 percent of total billed charges 6.31 10.73 50% of Eligible Charges PROPOFOL 10MG/ML 20ML J2704 HCPCS 636 RC 0409601025 NDC outpatient 10 ME 12.62 10.1 BCBS Louisiana PPO 10.1 percent of total billed charges 6.94 10.73 80% of billed charge PROPOFOL 10MG/ML 20ML J2704 HCPCS 636 RC 0409601025 NDC outpatient 10 ME 12.62 10.1 Cigna Commercial PPO 6.94 percent of total billed charges 6.94 10.73 55% of Billed Charges PROPOFOL 10MG/ML 20ML J2704 HCPCS 636 RC 0409601025 NDC inpatient 10 ME 12.62 6.31 IMA of Louisiana Commercial PPO 10.73 percent of total billed charges 6.31 10.73 Inpatient Reimbursement at 85% of Billed Charges PROPOFOL 10MG/ML 20ML J2704 HCPCS 636 RC 0409601025 NDC outpatient 10 ME 12.62 10.1 IMA of Louisiana Commercial PPO 10.73 percent of total billed charges 6.94 10.73 Reimbursement at 85% of billed charges TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC inpatient 15 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC outpatient 15 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC outpatient 15 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC inpatient 15 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC outpatient 15 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TEMAZEPAM 15MG CAPSULE 250 RC 0228207610 NDC outpatient 15 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SODIUM BICARB 8.4% INJ : 50ML SYR J3490 HCPCS 260 RC 0409663714 NDC inpatient 10 ML 107.1 53.55 BCBS Louisiana PPO 53.55 percent of total billed charges 53.55 91.04 50% of Eligible Charges SODIUM BICARB 8.4% INJ : 50ML SYR J3490 HCPCS 260 RC 0409663714 NDC outpatient 10 ML 107.1 85.68 BCBS Louisiana PPO 85.68 percent of total billed charges 58.91 91.04 80% of billed charge SODIUM BICARB 8.4% INJ : 50ML SYR J3490 HCPCS 260 RC 0409663714 NDC outpatient 10 ML 107.1 85.68 Cigna Commercial PPO 58.91 percent of total billed charges 58.91 91.04 55% of Billed Charges SODIUM BICARB 8.4% INJ : 50ML SYR J3490 HCPCS 260 RC 0409663714 NDC inpatient 10 ML 107.1 53.55 IMA of Louisiana Commercial PPO 91.04 percent of total billed charges 53.55 91.04 Inpatient Reimbursement at 85% of Billed Charges SODIUM BICARB 8.4% INJ : 50ML SYR J3490 HCPCS 260 RC 0409663714 NDC outpatient 10 ML 107.1 85.68 IMA of Louisiana Commercial PPO 91.04 percent of total billed charges 58.91 91.04 Reimbursement at 85% of billed charges SEVOFLURANE INH 250ML 250 RC 6679401525 NDC inpatient 250 ML 156 78 BCBS Louisiana PPO 78 percent of total billed charges 78 132.6 50% of Eligible Charges SEVOFLURANE INH 250ML 250 RC 6679401525 NDC outpatient 250 ML 156 124.8 BCBS Louisiana PPO 124.8 percent of total billed charges 85.8 132.6 80% of billed charge SEVOFLURANE INH 250ML 250 RC 6679401525 NDC outpatient 250 ML 156 124.8 Cigna Commercial PPO 85.8 percent of total billed charges 85.8 132.6 55% of Billed Charges SEVOFLURANE INH 250ML 250 RC 6679401525 NDC inpatient 250 ML 156 78 IMA of Louisiana Commercial PPO 132.6 percent of total billed charges 78 132.6 Inpatient Reimbursement at 85% of Billed Charges SEVOFLURANE INH 250ML 250 RC 6679401525 NDC outpatient 250 ML 156 124.8 IMA of Louisiana Commercial PPO 132.6 percent of total billed charges 85.8 132.6 Reimbursement at 85% of billed charges SEVOFLURANE INH 250ML 250 RC 6679401525 NDC outpatient 250 ML 156 124.8 Aetna Commercial PPO 85.8 percent of total billed charges 85.8 132.6 55 of billed Charges HYDROXYZINE PAMOATE 25MG CAPSULE Q0177 HCPCS 636 RC 6068769601 NDC inpatient 25 ME 1.71 0.86 BCBS Louisiana PPO 0.86 percent of total billed charges 0.86 1.45 50% of Eligible Charges HYDROXYZINE PAMOATE 25MG CAPSULE Q0177 HCPCS 636 RC 6068769601 NDC outpatient 25 ME 1.71 1.37 BCBS Louisiana PPO 1.37 percent of total billed charges 0.94 1.45 80% of billed charge HYDROXYZINE PAMOATE 25MG CAPSULE Q0177 HCPCS 636 RC 6068769601 NDC outpatient 25 ME 1.71 1.37 Cigna Commercial PPO 0.94 percent of total billed charges 0.94 1.45 55% of Billed Charges HYDROXYZINE PAMOATE 25MG CAPSULE Q0177 HCPCS 636 RC 6068769601 NDC inpatient 25 ME 1.71 0.86 IMA of Louisiana Commercial PPO 1.45 percent of total billed charges 0.86 1.45 Inpatient Reimbursement at 85% of Billed Charges HYDROXYZINE PAMOATE 25MG CAPSULE Q0177 HCPCS 636 RC 6068769601 NDC outpatient 25 ME 1.71 1.37 IMA of Louisiana Commercial PPO 1.45 percent of total billed charges 0.94 1.45 Reimbursement at 85% of billed charges BSS PLUS 15ML OPTH 250 RC 0065079515 NDC inpatient 15 ML 36 18 BCBS Louisiana PPO 18 percent of total billed charges 18 30.6 50% of Eligible Charges BSS PLUS 15ML OPTH 250 RC 0065079515 NDC outpatient 15 ML 36 28.8 BCBS Louisiana PPO 28.8 percent of total billed charges 19.8 30.6 80% of billed charge BSS PLUS 15ML OPTH 250 RC 0065079515 NDC outpatient 15 ML 36 28.8 Cigna Commercial PPO 19.8 percent of total billed charges 19.8 30.6 55% of Billed Charges BSS PLUS 15ML OPTH 250 RC 0065079515 NDC inpatient 15 ML 36 18 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 18 30.6 Inpatient Reimbursement at 85% of Billed Charges BSS PLUS 15ML OPTH 250 RC 0065079515 NDC outpatient 15 ML 36 28.8 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 19.8 30.6 Reimbursement at 85% of billed charges BSS PLUS 15ML OPTH 250 RC 0065079515 NDC outpatient 15 ML 36 28.8 Aetna Commercial PPO 19.8 percent of total billed charges 19.8 30.6 55 of billed Charges CEFUROXIME 1.5GM 20ML J0697 HCPCS 250 RC 2502111920 NDC inpatient 1.5 GR 21.54 10.77 BCBS Louisiana PPO 10.77 percent of total billed charges 10.77 18.31 50% of Eligible Charges CEFUROXIME 1.5GM 20ML J0697 HCPCS 250 RC 2502111920 NDC outpatient 1.5 GR 21.54 17.23 BCBS Louisiana PPO 17.23 percent of total billed charges 11.85 18.31 80% of billed charge CEFUROXIME 1.5GM 20ML J0697 HCPCS 250 RC 2502111920 NDC outpatient 1.5 GR 21.54 17.23 Cigna Commercial PPO 11.85 percent of total billed charges 11.85 18.31 55% of Billed Charges CEFUROXIME 1.5GM 20ML J0697 HCPCS 250 RC 2502111920 NDC inpatient 1.5 GR 21.54 10.77 IMA of Louisiana Commercial PPO 18.31 percent of total billed charges 10.77 18.31 Inpatient Reimbursement at 85% of Billed Charges CEFUROXIME 1.5GM 20ML J0697 HCPCS 250 RC 2502111920 NDC outpatient 1.5 GR 21.54 17.23 IMA of Louisiana Commercial PPO 18.31 percent of total billed charges 11.85 18.31 Reimbursement at 85% of billed charges DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC inpatient 20 ME 319.32 159.66 BCBS Louisiana PPO 159.66 percent of total billed charges 159.66 271.42 50% of Eligible Charges DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC outpatient 20 ME 319.32 255.46 BCBS Louisiana PPO 255.46 percent of total billed charges 175.63 271.42 80% of billed charge DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC outpatient 20 ME 319.32 255.46 Cigna Commercial PPO 175.63 percent of total billed charges 175.63 271.42 55% of Billed Charges DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC inpatient 20 ME 319.32 159.66 IMA of Louisiana Commercial PPO 271.42 percent of total billed charges 159.66 271.42 Inpatient Reimbursement at 85% of Billed Charges DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC outpatient 20 ME 319.32 255.46 IMA of Louisiana Commercial PPO 271.42 percent of total billed charges 175.63 271.42 Reimbursement at 85% of billed charges DOXAPRAM 20MG/ML 20ML INJ. 260 RC 0641601801 NDC outpatient 20 ME 319.32 255.46 Aetna Commercial PPO 175.63 percent of total billed charges 175.63 271.42 55 of billed Charges ALBUTEROL SULFATE 0.5% 2.5MG/0.5ML UD J7620 HCPCS 250 RC 0487990130 NDC inpatient 2.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ALBUTEROL SULFATE 0.5% 2.5MG/0.5ML UD J7620 HCPCS 250 RC 0487990130 NDC outpatient 2.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ALBUTEROL SULFATE 0.5% 2.5MG/0.5ML UD J7620 HCPCS 250 RC 0487990130 NDC outpatient 2.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ALBUTEROL SULFATE 0.5% 2.5MG/0.5ML UD J7620 HCPCS 250 RC 0487990130 NDC inpatient 2.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ALBUTEROL SULFATE 0.5% 2.5MG/0.5ML UD J7620 HCPCS 250 RC 0487990130 NDC outpatient 2.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC inpatient 50 ME 1.78 0.89 BCBS Louisiana PPO 0.89 percent of total billed charges 0.89 1.51 50% of Eligible Charges METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC outpatient 50 ME 1.78 1.42 BCBS Louisiana PPO 1.42 percent of total billed charges 0.98 1.51 80% of billed charge METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC outpatient 50 ME 1.78 1.42 Cigna Commercial PPO 0.98 percent of total billed charges 0.98 1.51 55% of Billed Charges METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC inpatient 50 ME 1.78 0.89 IMA of Louisiana Commercial PPO 1.51 percent of total billed charges 0.89 1.51 Inpatient Reimbursement at 85% of Billed Charges METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC outpatient 50 ME 1.78 1.42 IMA of Louisiana Commercial PPO 1.51 percent of total billed charges 0.98 1.51 Reimbursement at 85% of billed charges METOPROLOL SUCC XL 50MG TABLET 250 RC 5107917020 NDC outpatient 50 ME 1.78 1.42 Aetna Commercial PPO 0.98 percent of total billed charges 0.98 1.51 55 of billed Charges LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC inpatient 0.112 ME 2.92 1.46 BCBS Louisiana PPO 1.46 percent of total billed charges 1.46 2.48 50% of Eligible Charges LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC outpatient 0.112 ME 2.92 2.34 BCBS Louisiana PPO 2.34 percent of total billed charges 1.61 2.48 80% of billed charge LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC outpatient 0.112 ME 2.92 2.34 Cigna Commercial PPO 1.61 percent of total billed charges 1.61 2.48 55% of Billed Charges LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC inpatient 0.112 ME 2.92 1.46 IMA of Louisiana Commercial PPO 2.48 percent of total billed charges 1.46 2.48 Inpatient Reimbursement at 85% of Billed Charges LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC outpatient 0.112 ME 2.92 2.34 IMA of Louisiana Commercial PPO 2.48 percent of total billed charges 1.61 2.48 Reimbursement at 85% of billed charges LEVOTHYROXINE 112MCG TABLET 250 RC 6068750801 NDC outpatient 0.112 ME 2.92 2.34 Aetna Commercial PPO 1.61 percent of total billed charges 1.61 2.48 55 of billed Charges SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC inpatient 500 ME 1.16 0.58 BCBS Louisiana PPO 0.58 percent of total billed charges 0.58 0.99 50% of Eligible Charges SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC outpatient 500 ME 1.16 0.93 BCBS Louisiana PPO 0.93 percent of total billed charges 0.64 0.99 80% of billed charge SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC outpatient 500 ME 1.16 0.93 Cigna Commercial PPO 0.64 percent of total billed charges 0.64 0.99 55% of Billed Charges SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC inpatient 500 ME 1.16 0.58 IMA of Louisiana Commercial PPO 0.99 percent of total billed charges 0.58 0.99 Inpatient Reimbursement at 85% of Billed Charges SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC outpatient 500 ME 1.16 0.93 IMA of Louisiana Commercial PPO 0.99 percent of total billed charges 0.64 0.99 Reimbursement at 85% of billed charges SULFASALAZINE 500MG TABLET 250 RC 0013010110 NDC outpatient 500 ME 1.16 0.93 Aetna Commercial PPO 0.64 percent of total billed charges 0.64 0.99 55 of billed Charges HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC inpatient 50 ME 1.27 0.64 BCBS Louisiana PPO 0.64 percent of total billed charges 0.64 1.08 50% of Eligible Charges HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC outpatient 50 ME 1.27 1.02 BCBS Louisiana PPO 1.02 percent of total billed charges 0.7 1.08 80% of billed charge HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC outpatient 50 ME 1.27 1.02 Cigna Commercial PPO 0.7 percent of total billed charges 0.7 1.08 55% of Billed Charges HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC inpatient 50 ME 1.27 0.64 IMA of Louisiana Commercial PPO 1.08 percent of total billed charges 0.64 1.08 Inpatient Reimbursement at 85% of Billed Charges HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC outpatient 50 ME 1.27 1.02 IMA of Louisiana Commercial PPO 1.08 percent of total billed charges 0.7 1.08 Reimbursement at 85% of billed charges HYDRALAZINE 50MG TABLET 250 RC 6068783301 NDC outpatient 50 ME 1.27 1.02 Aetna Commercial PPO 0.7 percent of total billed charges 0.7 1.08 55 of billed Charges METHOCARBAMOL 1GM/10ML IV J2800 HCPCS 250 RC 5515022310 NDC inpatient 1 GR 19.87 9.94 BCBS Louisiana PPO 9.94 percent of total billed charges 9.94 16.89 50% of Eligible Charges METHOCARBAMOL 1GM/10ML IV J2800 HCPCS 250 RC 5515022310 NDC outpatient 1 GR 19.87 15.9 BCBS Louisiana PPO 15.9 percent of total billed charges 10.93 16.89 80% of billed charge METHOCARBAMOL 1GM/10ML IV J2800 HCPCS 250 RC 5515022310 NDC outpatient 1 GR 19.87 15.9 Cigna Commercial PPO 10.93 percent of total billed charges 10.93 16.89 55% of Billed Charges METHOCARBAMOL 1GM/10ML IV J2800 HCPCS 250 RC 5515022310 NDC inpatient 1 GR 19.87 9.94 IMA of Louisiana Commercial PPO 16.89 percent of total billed charges 9.94 16.89 Inpatient Reimbursement at 85% of Billed Charges METHOCARBAMOL 1GM/10ML IV J2800 HCPCS 250 RC 5515022310 NDC outpatient 1 GR 19.87 15.9 IMA of Louisiana Commercial PPO 16.89 percent of total billed charges 10.93 16.89 Reimbursement at 85% of billed charges CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CYCLOBENZAPRINE 10MG TABLET 250 RC 7288801405 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC inpatient 12.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC outpatient 12.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC outpatient 12.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC inpatient 12.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC outpatient 12.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HYDROCHLOROTHIAZIDE 12.5MG TABLET 250 RC 2315576401 NDC outpatient 12.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC inpatient 600 ME 1.3 0.65 BCBS Louisiana PPO 0.65 percent of total billed charges 0.65 1.11 50% of Eligible Charges GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC outpatient 600 ME 1.3 1.04 BCBS Louisiana PPO 1.04 percent of total billed charges 0.72 1.11 80% of billed charge GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC outpatient 600 ME 1.3 1.04 Cigna Commercial PPO 0.72 percent of total billed charges 0.72 1.11 55% of Billed Charges GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC inpatient 600 ME 1.3 0.65 IMA of Louisiana Commercial PPO 1.11 percent of total billed charges 0.65 1.11 Inpatient Reimbursement at 85% of Billed Charges GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC outpatient 600 ME 1.3 1.04 IMA of Louisiana Commercial PPO 1.11 percent of total billed charges 0.72 1.11 Reimbursement at 85% of billed charges GEMFIBROZIL 600MG TABLET 250 RC 6068722401 NDC outpatient 600 ME 1.3 1.04 Aetna Commercial PPO 0.72 percent of total billed charges 0.72 1.11 55 of billed Charges PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC inpatient 75 ME 1.95 0.98 BCBS Louisiana PPO 0.98 percent of total billed charges 0.98 1.66 50% of Eligible Charges PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC outpatient 75 ME 1.95 1.56 BCBS Louisiana PPO 1.56 percent of total billed charges 1.07 1.66 80% of billed charge PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC outpatient 75 ME 1.95 1.56 Cigna Commercial PPO 1.07 percent of total billed charges 1.07 1.66 55% of Billed Charges PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC inpatient 75 ME 1.95 0.98 IMA of Louisiana Commercial PPO 1.66 percent of total billed charges 0.98 1.66 Inpatient Reimbursement at 85% of Billed Charges PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC outpatient 75 ME 1.95 1.56 IMA of Louisiana Commercial PPO 1.66 percent of total billed charges 1.07 1.66 Reimbursement at 85% of billed charges PREGABALIN 75MG CAPSULE 250 RC 6068749511 NDC outpatient 75 ME 1.95 1.56 Aetna Commercial PPO 1.07 percent of total billed charges 1.07 1.66 55 of billed Charges LOVASTATIN 10MG TAB 250 RC 0093092606 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LOVASTATIN 10MG TAB 250 RC 0093092606 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LOVASTATIN 10MG TAB 250 RC 0093092606 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LOVASTATIN 10MG TAB 250 RC 0093092606 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LOVASTATIN 10MG TAB 250 RC 0093092606 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LOVASTATIN 10MG TAB 250 RC 0093092606 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC inpatient 100 ME 5.85 2.93 BCBS Louisiana PPO 2.93 percent of total billed charges 2.93 4.97 50% of Eligible Charges PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC outpatient 100 ME 5.85 4.68 BCBS Louisiana PPO 4.68 percent of total billed charges 3.22 4.97 80% of billed charge PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC outpatient 100 ME 5.85 4.68 Cigna Commercial PPO 3.22 percent of total billed charges 3.22 4.97 55% of Billed Charges PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC inpatient 100 ME 5.85 2.93 IMA of Louisiana Commercial PPO 4.97 percent of total billed charges 2.93 4.97 Inpatient Reimbursement at 85% of Billed Charges PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC outpatient 100 ME 5.85 4.68 IMA of Louisiana Commercial PPO 4.97 percent of total billed charges 3.22 4.97 Reimbursement at 85% of billed charges PHENYTOIN ER 100MG CAPSULE 250 RC 5167241113 NDC outpatient 100 ME 5.85 4.68 Aetna Commercial PPO 3.22 percent of total billed charges 3.22 4.97 55 of billed Charges WELCHOL 625MG TABLET 250 RC 2780819001 NDC inpatient 625 ME 1.56 0.78 BCBS Louisiana PPO 0.78 percent of total billed charges 0.78 1.33 50% of Eligible Charges WELCHOL 625MG TABLET 250 RC 2780819001 NDC outpatient 625 ME 1.56 1.25 BCBS Louisiana PPO 1.25 percent of total billed charges 0.86 1.33 80% of billed charge WELCHOL 625MG TABLET 250 RC 2780819001 NDC outpatient 625 ME 1.56 1.25 Cigna Commercial PPO 0.86 percent of total billed charges 0.86 1.33 55% of Billed Charges WELCHOL 625MG TABLET 250 RC 2780819001 NDC inpatient 625 ME 1.56 0.78 IMA of Louisiana Commercial PPO 1.33 percent of total billed charges 0.78 1.33 Inpatient Reimbursement at 85% of Billed Charges WELCHOL 625MG TABLET 250 RC 2780819001 NDC outpatient 625 ME 1.56 1.25 IMA of Louisiana Commercial PPO 1.33 percent of total billed charges 0.86 1.33 Reimbursement at 85% of billed charges WELCHOL 625MG TABLET 250 RC 2780819001 NDC outpatient 625 ME 1.56 1.25 Aetna Commercial PPO 0.86 percent of total billed charges 0.86 1.33 55 of billed Charges DUONEB INH 0.5MG/3ML UD J7620 HCPCS 250 RC 7620460060 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DUONEB INH 0.5MG/3ML UD J7620 HCPCS 250 RC 7620460060 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DUONEB INH 0.5MG/3ML UD J7620 HCPCS 250 RC 7620460060 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DUONEB INH 0.5MG/3ML UD J7620 HCPCS 250 RC 7620460060 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DUONEB INH 0.5MG/3ML UD J7620 HCPCS 250 RC 7620460060 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC inpatient 500 ML 242 121 BCBS Louisiana PPO 121 percent of total billed charges 121 205.7 50% of Eligible Charges HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC outpatient 500 ML 242 193.6 BCBS Louisiana PPO 193.6 percent of total billed charges 133.1 205.7 80% of billed charge HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC outpatient 500 ML 242 193.6 Cigna Commercial PPO 133.1 percent of total billed charges 133.1 205.7 55% of Billed Charges HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC inpatient 500 ML 242 121 IMA of Louisiana Commercial PPO 205.7 percent of total billed charges 121 205.7 Inpatient Reimbursement at 85% of Billed Charges HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC outpatient 500 ML 242 193.6 IMA of Louisiana Commercial PPO 205.7 percent of total billed charges 133.1 205.7 Reimbursement at 85% of billed charges HESPAN 6%/.9%NACL 500ML BAG 260 RC 0409724803 NDC outpatient 500 ML 242 193.6 Aetna Commercial PPO 133.1 percent of total billed charges 133.1 205.7 55 of billed Charges MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC inpatient 400 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC outpatient 400 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC outpatient 400 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC inpatient 400 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC outpatient 400 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MAGNESIUM OXIDE 400MG TABLET 250 RC 5865712012 NDC outpatient 400 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges MECLIZINE 25MG TABLET 250 RC 6068773001 NDC inpatient 25 ME 2.6 1.3 BCBS Louisiana PPO 1.3 percent of total billed charges 1.3 2.21 50% of Eligible Charges MECLIZINE 25MG TABLET 250 RC 6068773001 NDC outpatient 25 ME 2.6 2.08 BCBS Louisiana PPO 2.08 percent of total billed charges 1.43 2.21 80% of billed charge MECLIZINE 25MG TABLET 250 RC 6068773001 NDC outpatient 25 ME 2.6 2.08 Cigna Commercial PPO 1.43 percent of total billed charges 1.43 2.21 55% of Billed Charges MECLIZINE 25MG TABLET 250 RC 6068773001 NDC inpatient 25 ME 2.6 1.3 IMA of Louisiana Commercial PPO 2.21 percent of total billed charges 1.3 2.21 Inpatient Reimbursement at 85% of Billed Charges MECLIZINE 25MG TABLET 250 RC 6068773001 NDC outpatient 25 ME 2.6 2.08 IMA of Louisiana Commercial PPO 2.21 percent of total billed charges 1.43 2.21 Reimbursement at 85% of billed charges MECLIZINE 25MG TABLET 250 RC 6068773001 NDC outpatient 25 ME 2.6 2.08 Aetna Commercial PPO 1.43 percent of total billed charges 1.43 2.21 55 of billed Charges ALENDRONATE 70MG TAB 250 RC 6586232904 NDC inpatient 70 ME 1.8 0.9 BCBS Louisiana PPO 0.9 percent of total billed charges 0.9 1.53 50% of Eligible Charges ALENDRONATE 70MG TAB 250 RC 6586232904 NDC outpatient 70 ME 1.8 1.44 BCBS Louisiana PPO 1.44 percent of total billed charges 0.99 1.53 80% of billed charge ALENDRONATE 70MG TAB 250 RC 6586232904 NDC outpatient 70 ME 1.8 1.44 Cigna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55% of Billed Charges ALENDRONATE 70MG TAB 250 RC 6586232904 NDC inpatient 70 ME 1.8 0.9 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.9 1.53 Inpatient Reimbursement at 85% of Billed Charges ALENDRONATE 70MG TAB 250 RC 6586232904 NDC outpatient 70 ME 1.8 1.44 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.99 1.53 Reimbursement at 85% of billed charges ALENDRONATE 70MG TAB 250 RC 6586232904 NDC outpatient 70 ME 1.8 1.44 Aetna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55 of billed Charges ADVAIR 250/50MCG INHALER J7799 HCPCS 250 RC 0378932132 NDC inpatient 250 UN 558.96 279.48 BCBS Louisiana PPO 279.48 percent of total billed charges 279.48 475.12 50% of Eligible Charges ADVAIR 250/50MCG INHALER J7799 HCPCS 250 RC 0378932132 NDC outpatient 250 UN 558.96 447.17 BCBS Louisiana PPO 447.17 percent of total billed charges 307.43 475.12 80% of billed charge ADVAIR 250/50MCG INHALER J7799 HCPCS 250 RC 0378932132 NDC outpatient 250 UN 558.96 447.17 Cigna Commercial PPO 307.43 percent of total billed charges 307.43 475.12 55% of Billed Charges ADVAIR 250/50MCG INHALER J7799 HCPCS 250 RC 0378932132 NDC inpatient 250 UN 558.96 279.48 IMA of Louisiana Commercial PPO 475.12 percent of total billed charges 279.48 475.12 Inpatient Reimbursement at 85% of Billed Charges ADVAIR 250/50MCG INHALER J7799 HCPCS 250 RC 0378932132 NDC outpatient 250 UN 558.96 447.17 IMA of Louisiana Commercial PPO 475.12 percent of total billed charges 307.43 475.12 Reimbursement at 85% of billed charges IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC inpatient 150 ME 1.44 0.72 BCBS Louisiana PPO 0.72 percent of total billed charges 0.72 1.22 50% of Eligible Charges IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC outpatient 150 ME 1.44 1.15 BCBS Louisiana PPO 1.15 percent of total billed charges 0.79 1.22 80% of billed charge IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC outpatient 150 ME 1.44 1.15 Cigna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55% of Billed Charges IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC inpatient 150 ME 1.44 0.72 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.72 1.22 Inpatient Reimbursement at 85% of Billed Charges IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC outpatient 150 ME 1.44 1.15 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.79 1.22 Reimbursement at 85% of billed charges IRBESARTAN 150MG TABLET 250 RC 3172273090 NDC outpatient 150 ME 1.44 1.15 Aetna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55 of billed Charges METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC inpatient 25 ME 1.83 0.92 BCBS Louisiana PPO 0.92 percent of total billed charges 0.92 1.56 50% of Eligible Charges METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC outpatient 25 ME 1.83 1.46 BCBS Louisiana PPO 1.46 percent of total billed charges 1.01 1.56 80% of billed charge METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC outpatient 25 ME 1.83 1.46 Cigna Commercial PPO 1.01 percent of total billed charges 1.01 1.56 55% of Billed Charges METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC inpatient 25 ME 1.83 0.92 IMA of Louisiana Commercial PPO 1.56 percent of total billed charges 0.92 1.56 Inpatient Reimbursement at 85% of Billed Charges METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC outpatient 25 ME 1.83 1.46 IMA of Louisiana Commercial PPO 1.56 percent of total billed charges 1.01 1.56 Reimbursement at 85% of billed charges METOPROLOL SUCC XL 25MG TABLET 250 RC 6068739011 NDC outpatient 25 ME 1.83 1.46 Aetna Commercial PPO 1.01 percent of total billed charges 1.01 1.56 55 of billed Charges PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PAROXETINE HCL 20MG TABLET 250 RC 0904567761 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC inpatient 0.025 ME 1.09 0.55 BCBS Louisiana PPO 0.55 percent of total billed charges 0.55 0.93 50% of Eligible Charges DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC outpatient 0.025 ME 1.09 0.87 BCBS Louisiana PPO 0.87 percent of total billed charges 0.6 0.93 80% of billed charge DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC outpatient 0.025 ME 1.09 0.87 Cigna Commercial PPO 0.6 percent of total billed charges 0.6 0.93 55% of Billed Charges DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC inpatient 0.025 ME 1.09 0.55 IMA of Louisiana Commercial PPO 0.93 percent of total billed charges 0.55 0.93 Inpatient Reimbursement at 85% of Billed Charges DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC outpatient 0.025 ME 1.09 0.87 IMA of Louisiana Commercial PPO 0.93 percent of total billed charges 0.6 0.93 Reimbursement at 85% of billed charges DIPHENOXYLATE/ATROPINE 2.5/.025MG TAB 250 RC 0406123601 NDC outpatient 0.025 ME 1.09 0.87 Aetna Commercial PPO 0.6 percent of total billed charges 0.6 0.93 55 of billed Charges DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC inpatient 2 ME 2.9 1.45 BCBS Louisiana PPO 1.45 percent of total billed charges 1.45 2.47 50% of Eligible Charges DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC outpatient 2 ME 2.9 2.32 BCBS Louisiana PPO 2.32 percent of total billed charges 1.6 2.47 80% of billed charge DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC outpatient 2 ME 2.9 2.32 Cigna Commercial PPO 1.6 percent of total billed charges 1.6 2.47 55% of Billed Charges DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC inpatient 2 ME 2.9 1.45 IMA of Louisiana Commercial PPO 2.47 percent of total billed charges 1.45 2.47 Inpatient Reimbursement at 85% of Billed Charges DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC outpatient 2 ME 2.9 2.32 IMA of Louisiana Commercial PPO 2.47 percent of total billed charges 1.6 2.47 Reimbursement at 85% of billed charges DOXAZOSIN (CARDURA) 2MG TABLET 250 RC 6808485111 NDC outpatient 2 ME 2.9 2.32 Aetna Commercial PPO 1.6 percent of total billed charges 1.6 2.47 55 of billed Charges OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges OXYBUTYNIN 5MG TAB 250 RC 0832003889 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges NASAL SPRAY 250 RC 0904386575 NDC inpatient 1 EA 4.74 2.37 BCBS Louisiana PPO 2.37 percent of total billed charges 2.37 4.03 50% of Eligible Charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 BCBS Louisiana PPO 3.79 percent of total billed charges 2.61 4.03 80% of billed charge NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 Cigna Commercial PPO 2.61 percent of total billed charges 2.61 4.03 55% of Billed Charges NASAL SPRAY 250 RC 0904386575 NDC inpatient 1 EA 4.74 2.37 IMA of Louisiana Commercial PPO 4.03 percent of total billed charges 2.37 4.03 Inpatient Reimbursement at 85% of Billed Charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 IMA of Louisiana Commercial PPO 4.03 percent of total billed charges 2.61 4.03 Reimbursement at 85% of billed charges NASAL SPRAY 250 RC 0904386575 NDC outpatient 1 EA 4.74 3.79 Aetna Commercial PPO 2.61 percent of total billed charges 2.61 4.03 55 of billed Charges PREDNISONE 5MG TABLET J7510 HCPCS 250 RC 6068712201 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PREDNISONE 5MG TABLET J7510 HCPCS 250 RC 6068712201 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PREDNISONE 5MG TABLET J7510 HCPCS 250 RC 6068712201 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PREDNISONE 5MG TABLET J7510 HCPCS 250 RC 6068712201 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PREDNISONE 5MG TABLET J7510 HCPCS 250 RC 6068712201 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC inpatient 3.125 ME 3.36 1.68 BCBS Louisiana PPO 1.68 percent of total billed charges 1.68 2.86 50% of Eligible Charges CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC outpatient 3.125 ME 3.36 2.69 BCBS Louisiana PPO 2.69 percent of total billed charges 1.85 2.86 80% of billed charge CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC outpatient 3.125 ME 3.36 2.69 Cigna Commercial PPO 1.85 percent of total billed charges 1.85 2.86 55% of Billed Charges CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC inpatient 3.125 ME 3.36 1.68 IMA of Louisiana Commercial PPO 2.86 percent of total billed charges 1.68 2.86 Inpatient Reimbursement at 85% of Billed Charges CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC outpatient 3.125 ME 3.36 2.69 IMA of Louisiana Commercial PPO 2.86 percent of total billed charges 1.85 2.86 Reimbursement at 85% of billed charges CARVEDILOL 3.125MG TABLET 250 RC 0904730561 NDC outpatient 3.125 ME 3.36 2.69 Aetna Commercial PPO 1.85 percent of total billed charges 1.85 2.86 55 of billed Charges TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC inpatient 250 ME 1.37 0.69 BCBS Louisiana PPO 0.69 percent of total billed charges 0.69 1.16 50% of Eligible Charges TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC outpatient 250 ME 1.37 1.1 BCBS Louisiana PPO 1.1 percent of total billed charges 0.75 1.16 80% of billed charge TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC outpatient 250 ME 1.37 1.1 Cigna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55% of Billed Charges TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC inpatient 250 ME 1.37 0.69 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.69 1.16 Inpatient Reimbursement at 85% of Billed Charges TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC outpatient 250 ME 1.37 1.1 IMA of Louisiana Commercial PPO 1.16 percent of total billed charges 0.75 1.16 Reimbursement at 85% of billed charges TERBINAFINE 250MG TABLET 250 RC 6586207930 NDC outpatient 250 ME 1.37 1.1 Aetna Commercial PPO 0.75 percent of total billed charges 0.75 1.16 55 of billed Charges CARMEX .15OZ 250 RC 8307812317 NDC inpatient 1 EA 6.1 3.05 BCBS Louisiana PPO 3.05 percent of total billed charges 3.05 5.19 50% of Eligible Charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 BCBS Louisiana PPO 4.88 percent of total billed charges 3.36 5.19 80% of billed charge CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 Cigna Commercial PPO 3.36 percent of total billed charges 3.36 5.19 55% of Billed Charges CARMEX .15OZ 250 RC 8307812317 NDC inpatient 1 EA 6.1 3.05 IMA of Louisiana Commercial PPO 5.19 percent of total billed charges 3.05 5.19 Inpatient Reimbursement at 85% of Billed Charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 IMA of Louisiana Commercial PPO 5.19 percent of total billed charges 3.36 5.19 Reimbursement at 85% of billed charges CARMEX .15OZ 250 RC 8307812317 NDC outpatient 1 EA 6.1 4.88 Aetna Commercial PPO 3.36 percent of total billed charges 3.36 5.19 55 of billed Charges VANCOMYCIN 1GM ADD-VANTAGE J3370 HCPCS 260 RC 0409653501 NDC inpatient 1 GR 36 18 BCBS Louisiana PPO 18 percent of total billed charges 18 30.6 50% of Eligible Charges VANCOMYCIN 1GM ADD-VANTAGE J3370 HCPCS 260 RC 0409653501 NDC outpatient 1 GR 36 28.8 BCBS Louisiana PPO 28.8 percent of total billed charges 19.8 30.6 80% of billed charge VANCOMYCIN 1GM ADD-VANTAGE J3370 HCPCS 260 RC 0409653501 NDC outpatient 1 GR 36 28.8 Cigna Commercial PPO 19.8 percent of total billed charges 19.8 30.6 55% of Billed Charges VANCOMYCIN 1GM ADD-VANTAGE J3370 HCPCS 260 RC 0409653501 NDC inpatient 1 GR 36 18 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 18 30.6 Inpatient Reimbursement at 85% of Billed Charges VANCOMYCIN 1GM ADD-VANTAGE J3370 HCPCS 260 RC 0409653501 NDC outpatient 1 GR 36 28.8 IMA of Louisiana Commercial PPO 30.6 percent of total billed charges 19.8 30.6 Reimbursement at 85% of billed charges HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC inpatient 3 ML 611.02 305.51 BCBS Louisiana PPO 305.51 percent of total billed charges 305.51 519.37 50% of Eligible Charges HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC outpatient 3 ML 611.02 488.82 BCBS Louisiana PPO 488.82 percent of total billed charges 336.06 519.37 80% of billed charge HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC outpatient 3 ML 611.02 488.82 Cigna Commercial PPO 336.06 percent of total billed charges 336.06 519.37 55% of Billed Charges HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC inpatient 3 ML 611.02 305.51 IMA of Louisiana Commercial PPO 519.37 percent of total billed charges 305.51 519.37 Inpatient Reimbursement at 85% of Billed Charges HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC outpatient 3 ML 611.02 488.82 IMA of Louisiana Commercial PPO 519.37 percent of total billed charges 336.06 519.37 Reimbursement at 85% of billed charges HUMALOG 100U/ML 3ML SYRINGE 250 RC 0002879959 NDC outpatient 3 ML 611.02 488.82 Aetna Commercial PPO 336.06 percent of total billed charges 336.06 519.37 55 of billed Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC inpatient 1 EA 9.45 4.73 BCBS Louisiana PPO 4.73 percent of total billed charges 4.73 8.03 50% of Eligible Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 BCBS Louisiana PPO 7.56 percent of total billed charges 5.2 8.03 80% of billed charge MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 Cigna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55% of Billed Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC inpatient 1 EA 9.45 4.73 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 4.73 8.03 Inpatient Reimbursement at 85% of Billed Charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 IMA of Louisiana Commercial PPO 8.03 percent of total billed charges 5.2 8.03 Reimbursement at 85% of billed charges MYCOSTATIN CREAM NON-FORMULARY 250 RC 5486802420 NDC outpatient 1 EA 9.45 7.56 Aetna Commercial PPO 5.2 percent of total billed charges 5.2 8.03 55 of billed Charges LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC inpatient 2.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC outpatient 2.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC outpatient 2.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC inpatient 2.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC outpatient 2.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LISINOPRIL 2.5MG TABLET 250 RC 4354735110 NDC outpatient 2.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC inpatient 1 GR 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC outpatient 1 GR 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC outpatient 1 GR 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC inpatient 1 GR 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC outpatient 1 GR 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges SUCRALAFATE 1GM TAB 250 RC 6068769501 NDC outpatient 1 GR 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC inpatient 2 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC outpatient 2 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC outpatient 2 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC inpatient 2 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC outpatient 2 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges HYDROMORPHONE 2MG TABLET 250 RC 0406324301 NDC outpatient 2 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC inpatient 650 ME 2.1 1.05 BCBS Louisiana PPO 1.05 percent of total billed charges 1.05 1.79 50% of Eligible Charges ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC outpatient 650 ME 2.1 1.68 BCBS Louisiana PPO 1.68 percent of total billed charges 1.16 1.79 80% of billed charge ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC outpatient 650 ME 2.1 1.68 Cigna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55% of Billed Charges ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC inpatient 650 ME 2.1 1.05 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.05 1.79 Inpatient Reimbursement at 85% of Billed Charges ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC outpatient 650 ME 2.1 1.68 IMA of Louisiana Commercial PPO 1.79 percent of total billed charges 1.16 1.79 Reimbursement at 85% of billed charges ACETAMINOPHEN SUPP : 650MG 250 RC 4580273032 NDC outpatient 650 ME 2.1 1.68 Aetna Commercial PPO 1.16 percent of total billed charges 1.16 1.79 55 of billed Charges HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC inpatient 3 ML 77.06 38.53 BCBS Louisiana PPO 38.53 percent of total billed charges 38.53 65.5 50% of Eligible Charges HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC outpatient 3 ML 77.06 61.65 BCBS Louisiana PPO 61.65 percent of total billed charges 42.38 65.5 80% of billed charge HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC outpatient 3 ML 77.06 61.65 Cigna Commercial PPO 42.38 percent of total billed charges 42.38 65.5 55% of Billed Charges HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC inpatient 3 ML 77.06 38.53 IMA of Louisiana Commercial PPO 65.5 percent of total billed charges 38.53 65.5 Inpatient Reimbursement at 85% of Billed Charges HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC outpatient 3 ML 77.06 61.65 IMA of Louisiana Commercial PPO 65.5 percent of total billed charges 42.38 65.5 Reimbursement at 85% of billed charges HUMULIN R 100U/ML 3ML VIAL 250 RC 0002021301 NDC outpatient 3 ML 77.06 61.65 Aetna Commercial PPO 42.38 percent of total billed charges 42.38 65.5 55 of billed Charges DAPTOMYCIN 500MG IVPB J0878 HCPCS 260 RC 7059403402 NDC inpatient 500 ME 72 36 BCBS Louisiana PPO 36 percent of total billed charges 36 61.2 50% of Eligible Charges DAPTOMYCIN 500MG IVPB J0878 HCPCS 260 RC 7059403402 NDC outpatient 500 ME 72 57.6 BCBS Louisiana PPO 57.6 percent of total billed charges 39.6 61.2 80% of billed charge DAPTOMYCIN 500MG IVPB J0878 HCPCS 260 RC 7059403402 NDC outpatient 500 ME 72 57.6 Cigna Commercial PPO 39.6 percent of total billed charges 39.6 61.2 55% of Billed Charges DAPTOMYCIN 500MG IVPB J0878 HCPCS 260 RC 7059403402 NDC inpatient 500 ME 72 36 IMA of Louisiana Commercial PPO 61.2 percent of total billed charges 36 61.2 Inpatient Reimbursement at 85% of Billed Charges DAPTOMYCIN 500MG IVPB J0878 HCPCS 260 RC 7059403402 NDC outpatient 500 ME 72 57.6 IMA of Louisiana Commercial PPO 61.2 percent of total billed charges 39.6 61.2 Reimbursement at 85% of billed charges PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC inpatient 30 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC outpatient 30 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC outpatient 30 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC inpatient 30 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC outpatient 30 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges PIOGLITAZONE (ACTOS) TABLET : 30MG 250 RC 6586251330 NDC outpatient 30 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC inpatient 750 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC outpatient 750 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC outpatient 750 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC inpatient 750 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC outpatient 750 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METHOCARBAMOL 750MG TABLET 250 RC 3172253405 NDC outpatient 750 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LEVEMIR 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0169643210 NDC inpatient 3 ML 464.82 232.41 BCBS Louisiana PPO 232.41 percent of total billed charges 232.41 395.1 50% of Eligible Charges LEVEMIR 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0169643210 NDC outpatient 3 ML 464.82 371.86 BCBS Louisiana PPO 371.86 percent of total billed charges 255.65 395.1 80% of billed charge LEVEMIR 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0169643210 NDC outpatient 3 ML 464.82 371.86 Cigna Commercial PPO 255.65 percent of total billed charges 255.65 395.1 55% of Billed Charges LEVEMIR 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0169643210 NDC inpatient 3 ML 464.82 232.41 IMA of Louisiana Commercial PPO 395.1 percent of total billed charges 232.41 395.1 Inpatient Reimbursement at 85% of Billed Charges LEVEMIR 100U/ML 3ML SYRINGE J1815 HCPCS 250 RC 0169643210 NDC outpatient 3 ML 464.82 371.86 IMA of Louisiana Commercial PPO 395.1 percent of total billed charges 255.65 395.1 Reimbursement at 85% of billed charges FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC inpatient 150 ME 3.42 1.71 BCBS Louisiana PPO 1.71 percent of total billed charges 1.71 2.91 50% of Eligible Charges FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC outpatient 150 ME 3.42 2.74 BCBS Louisiana PPO 2.74 percent of total billed charges 1.88 2.91 80% of billed charge FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC outpatient 150 ME 3.42 2.74 Cigna Commercial PPO 1.88 percent of total billed charges 1.88 2.91 55% of Billed Charges FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC inpatient 150 ME 3.42 1.71 IMA of Louisiana Commercial PPO 2.91 percent of total billed charges 1.71 2.91 Inpatient Reimbursement at 85% of Billed Charges FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC outpatient 150 ME 3.42 2.74 IMA of Louisiana Commercial PPO 2.91 percent of total billed charges 1.88 2.91 Reimbursement at 85% of billed charges FLUCONAZOLE 150MG TABLET 250 RC 6255999212 NDC outpatient 150 ME 3.42 2.74 Aetna Commercial PPO 1.88 percent of total billed charges 1.88 2.91 55 of billed Charges CALCIUM CITRATE +VIT D3 NON-FORMULARY J8499 HCPCS 250 RC 7985404039 NDC inpatient 500 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CALCIUM CITRATE +VIT D3 NON-FORMULARY J8499 HCPCS 250 RC 7985404039 NDC outpatient 500 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CALCIUM CITRATE +VIT D3 NON-FORMULARY J8499 HCPCS 250 RC 7985404039 NDC outpatient 500 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CALCIUM CITRATE +VIT D3 NON-FORMULARY J8499 HCPCS 250 RC 7985404039 NDC inpatient 500 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CALCIUM CITRATE +VIT D3 NON-FORMULARY J8499 HCPCS 250 RC 7985404039 NDC outpatient 500 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC inpatient 10 ME 125.84 62.92 BCBS Louisiana PPO 62.92 percent of total billed charges 62.92 106.96 50% of Eligible Charges MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC outpatient 10 ME 125.84 100.67 BCBS Louisiana PPO 100.67 percent of total billed charges 69.21 106.96 80% of billed charge MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC outpatient 10 ME 125.84 100.67 Cigna Commercial PPO 69.21 percent of total billed charges 69.21 106.96 55% of Billed Charges MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC inpatient 10 ME 125.84 62.92 IMA of Louisiana Commercial PPO 106.96 percent of total billed charges 62.92 106.96 Inpatient Reimbursement at 85% of Billed Charges MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC outpatient 10 ME 125.84 100.67 IMA of Louisiana Commercial PPO 106.96 percent of total billed charges 69.21 106.96 Reimbursement at 85% of billed charges MAXALT 10MG TAB NON-FORMULARY 250 RC 5486842511 NDC outpatient 10 ME 125.84 100.67 Aetna Commercial PPO 69.21 percent of total billed charges 69.21 106.96 55 of billed Charges ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC inpatient 4 ME 1.74 0.87 BCBS Louisiana PPO 0.87 percent of total billed charges 0.87 1.48 50% of Eligible Charges ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC outpatient 4 ME 1.74 1.39 BCBS Louisiana PPO 1.39 percent of total billed charges 0.96 1.48 80% of billed charge ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC outpatient 4 ME 1.74 1.39 Cigna Commercial PPO 0.96 percent of total billed charges 0.96 1.48 55% of Billed Charges ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC inpatient 4 ME 1.74 0.87 IMA of Louisiana Commercial PPO 1.48 percent of total billed charges 0.87 1.48 Inpatient Reimbursement at 85% of Billed Charges ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC outpatient 4 ME 1.74 1.39 IMA of Louisiana Commercial PPO 1.48 percent of total billed charges 0.96 1.48 Reimbursement at 85% of billed charges ONDANSETRON 4MG TABLET 250 RC 5026862115 NDC outpatient 4 ME 1.74 1.39 Aetna Commercial PPO 0.96 percent of total billed charges 0.96 1.48 55 of billed Charges GEODON 20MG/ML VIAL 260 RC 7226616010 NDC inpatient 20 ME 99.54 49.77 BCBS Louisiana PPO 49.77 percent of total billed charges 49.77 84.61 50% of Eligible Charges GEODON 20MG/ML VIAL 260 RC 7226616010 NDC outpatient 20 ME 99.54 79.63 BCBS Louisiana PPO 79.63 percent of total billed charges 54.75 84.61 80% of billed charge GEODON 20MG/ML VIAL 260 RC 7226616010 NDC outpatient 20 ME 99.54 79.63 Cigna Commercial PPO 54.75 percent of total billed charges 54.75 84.61 55% of Billed Charges GEODON 20MG/ML VIAL 260 RC 7226616010 NDC inpatient 20 ME 99.54 49.77 IMA of Louisiana Commercial PPO 84.61 percent of total billed charges 49.77 84.61 Inpatient Reimbursement at 85% of Billed Charges GEODON 20MG/ML VIAL 260 RC 7226616010 NDC outpatient 20 ME 99.54 79.63 IMA of Louisiana Commercial PPO 84.61 percent of total billed charges 54.75 84.61 Reimbursement at 85% of billed charges GEODON 20MG/ML VIAL 260 RC 7226616010 NDC outpatient 20 ME 99.54 79.63 Aetna Commercial PPO 54.75 percent of total billed charges 54.75 84.61 55 of billed Charges NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges NITROFURANTOIN 50MG CAPSULE 250 RC 7075641111 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC inpatient 5 ME 75.72 37.86 BCBS Louisiana PPO 37.86 percent of total billed charges 37.86 64.36 50% of Eligible Charges ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC outpatient 5 ME 75.72 60.58 BCBS Louisiana PPO 60.58 percent of total billed charges 41.65 64.36 80% of billed charge ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC outpatient 5 ME 75.72 60.58 Cigna Commercial PPO 41.65 percent of total billed charges 41.65 64.36 55% of Billed Charges ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC inpatient 5 ME 75.72 37.86 IMA of Louisiana Commercial PPO 64.36 percent of total billed charges 37.86 64.36 Inpatient Reimbursement at 85% of Billed Charges ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC outpatient 5 ME 75.72 60.58 IMA of Louisiana Commercial PPO 64.36 percent of total billed charges 41.65 64.36 Reimbursement at 85% of billed charges ARIPIPRAZOLE 5MG TAB NON-FORMULARY 250 RC 5914800713 NDC outpatient 5 ME 75.72 60.58 Aetna Commercial PPO 41.65 percent of total billed charges 41.65 64.36 55 of billed Charges SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC inpatient 25 ML 16.05 8.03 BCBS Louisiana PPO 8.03 percent of total billed charges 8.03 13.64 50% of Eligible Charges SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC outpatient 25 ML 16.05 12.84 BCBS Louisiana PPO 12.84 percent of total billed charges 8.83 13.64 80% of billed charge SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC outpatient 25 ML 16.05 12.84 Cigna Commercial PPO 8.83 percent of total billed charges 8.83 13.64 55% of Billed Charges SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC inpatient 25 ML 16.05 8.03 IMA of Louisiana Commercial PPO 13.64 percent of total billed charges 8.03 13.64 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC outpatient 25 ML 16.05 12.84 IMA of Louisiana Commercial PPO 13.64 percent of total billed charges 8.83 13.64 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 25ML BAG 260 RC 0338004910 NDC outpatient 25 ML 16.05 12.84 Aetna Commercial PPO 8.83 percent of total billed charges 8.83 13.64 55 of billed Charges SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC inpatient 50 ME 2.66 1.33 BCBS Louisiana PPO 1.33 percent of total billed charges 1.33 2.26 50% of Eligible Charges SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC outpatient 50 ME 2.66 2.13 BCBS Louisiana PPO 2.13 percent of total billed charges 1.46 2.26 80% of billed charge SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC outpatient 50 ME 2.66 2.13 Cigna Commercial PPO 1.46 percent of total billed charges 1.46 2.26 55% of Billed Charges SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC inpatient 50 ME 2.66 1.33 IMA of Louisiana Commercial PPO 2.26 percent of total billed charges 1.33 2.26 Inpatient Reimbursement at 85% of Billed Charges SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC outpatient 50 ME 2.66 2.13 IMA of Louisiana Commercial PPO 2.26 percent of total billed charges 1.46 2.26 Reimbursement at 85% of billed charges SUMATRIPTAN SUCC 50MG TAB 250 RC 6586214736 NDC outpatient 50 ME 2.66 2.13 Aetna Commercial PPO 1.46 percent of total billed charges 1.46 2.26 55 of billed Charges METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METOCLOPRAMIDE 10MG TABLET 250 RC 5107988801 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DOXYCYCLINE 50MG CAPSULE 250 RC 6838278201 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC inpatient 325 ME 4.82 2.41 BCBS Louisiana PPO 2.41 percent of total billed charges 2.41 4.1 50% of Eligible Charges OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC outpatient 325 ME 4.82 3.86 BCBS Louisiana PPO 3.86 percent of total billed charges 2.65 4.1 80% of billed charge OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC outpatient 325 ME 4.82 3.86 Cigna Commercial PPO 2.65 percent of total billed charges 2.65 4.1 55% of Billed Charges OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC inpatient 325 ME 4.82 2.41 IMA of Louisiana Commercial PPO 4.1 percent of total billed charges 2.41 4.1 Inpatient Reimbursement at 85% of Billed Charges OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC outpatient 325 ME 4.82 3.86 IMA of Louisiana Commercial PPO 4.1 percent of total billed charges 2.65 4.1 Reimbursement at 85% of billed charges OXYCODONE/ACETAMINOPHEN 7.5/325MG TABLET 250 RC 6808469901 NDC outpatient 325 ME 4.82 3.86 Aetna Commercial PPO 2.65 percent of total billed charges 2.65 4.1 55 of billed Charges TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TORSEMIDE 20MG TABLET 250 RC 3172253101 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC inpatient 160 ME 1.05 0.53 BCBS Louisiana PPO 0.53 percent of total billed charges 0.53 0.89 50% of Eligible Charges BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC outpatient 160 ME 1.05 0.84 BCBS Louisiana PPO 0.84 percent of total billed charges 0.58 0.89 80% of billed charge BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC outpatient 160 ME 1.05 0.84 Cigna Commercial PPO 0.58 percent of total billed charges 0.58 0.89 55% of Billed Charges BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC inpatient 160 ME 1.05 0.53 IMA of Louisiana Commercial PPO 0.89 percent of total billed charges 0.53 0.89 Inpatient Reimbursement at 85% of Billed Charges BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC outpatient 160 ME 1.05 0.84 IMA of Louisiana Commercial PPO 0.89 percent of total billed charges 0.58 0.89 Reimbursement at 85% of billed charges BACTRIM DS 800/160MG TAB NON-FORMULARY 250 RC 5486803370 NDC outpatient 160 ME 1.05 0.84 Aetna Commercial PPO 0.58 percent of total billed charges 0.58 0.89 55 of billed Charges FORMOTEROL/MOMETASONE 200/5MCG INH NON-F J8499 HCPCS 250 RC 5009019160 NDC inpatient 5 UN 820.2 410.1 BCBS Louisiana PPO 410.1 percent of total billed charges 410.1 697.17 50% of Eligible Charges FORMOTEROL/MOMETASONE 200/5MCG INH NON-F J8499 HCPCS 250 RC 5009019160 NDC outpatient 5 UN 820.2 656.16 BCBS Louisiana PPO 656.16 percent of total billed charges 451.11 697.17 80% of billed charge FORMOTEROL/MOMETASONE 200/5MCG INH NON-F J8499 HCPCS 250 RC 5009019160 NDC outpatient 5 UN 820.2 656.16 Cigna Commercial PPO 451.11 percent of total billed charges 451.11 697.17 55% of Billed Charges FORMOTEROL/MOMETASONE 200/5MCG INH NON-F J8499 HCPCS 250 RC 5009019160 NDC inpatient 5 UN 820.2 410.1 IMA of Louisiana Commercial PPO 697.17 percent of total billed charges 410.1 697.17 Inpatient Reimbursement at 85% of Billed Charges FORMOTEROL/MOMETASONE 200/5MCG INH NON-F J8499 HCPCS 250 RC 5009019160 NDC outpatient 5 UN 820.2 656.16 IMA of Louisiana Commercial PPO 697.17 percent of total billed charges 451.11 697.17 Reimbursement at 85% of billed charges FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC inpatient 50 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC outpatient 50 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC outpatient 50 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC inpatient 50 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC outpatient 50 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FLECAINIDE ACET 50MG TAB 250 RC 4280681701 NDC outpatient 50 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC inpatient 0.25 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC outpatient 0.25 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC outpatient 0.25 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC inpatient 0.25 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC outpatient 0.25 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ALPRAZOLAM 0.25MG TABLET 250 RC 6586267601 NDC outpatient 0.25 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC inpatient 50 ME 1.43 0.72 BCBS Louisiana PPO 0.72 percent of total billed charges 0.72 1.22 50% of Eligible Charges QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC outpatient 50 ME 1.43 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.79 1.22 80% of billed charge QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC outpatient 50 ME 1.43 1.14 Cigna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55% of Billed Charges QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC inpatient 50 ME 1.43 0.72 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.72 1.22 Inpatient Reimbursement at 85% of Billed Charges QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC outpatient 50 ME 1.43 1.14 IMA of Louisiana Commercial PPO 1.22 percent of total billed charges 0.79 1.22 Reimbursement at 85% of billed charges QUETIAPINE 50MG TABLET 250 RC 6068733801 NDC outpatient 50 ME 1.43 1.14 Aetna Commercial PPO 0.79 percent of total billed charges 0.79 1.22 55 of billed Charges HYDROMORPHONE 4MG/ML 1ML NON-FORMULARY J8499 HCPCS 250 RC 7604500911 NDC inpatient 1 ME 15.78 7.89 BCBS Louisiana PPO 7.89 percent of total billed charges 7.89 13.41 50% of Eligible Charges HYDROMORPHONE 4MG/ML 1ML NON-FORMULARY J8499 HCPCS 250 RC 7604500911 NDC outpatient 1 ME 15.78 12.62 BCBS Louisiana PPO 12.62 percent of total billed charges 8.68 13.41 80% of billed charge HYDROMORPHONE 4MG/ML 1ML NON-FORMULARY J8499 HCPCS 250 RC 7604500911 NDC outpatient 1 ME 15.78 12.62 Cigna Commercial PPO 8.68 percent of total billed charges 8.68 13.41 55% of Billed Charges HYDROMORPHONE 4MG/ML 1ML NON-FORMULARY J8499 HCPCS 250 RC 7604500911 NDC inpatient 1 ME 15.78 7.89 IMA of Louisiana Commercial PPO 13.41 percent of total billed charges 7.89 13.41 Inpatient Reimbursement at 85% of Billed Charges HYDROMORPHONE 4MG/ML 1ML NON-FORMULARY J8499 HCPCS 250 RC 7604500911 NDC outpatient 1 ME 15.78 12.62 IMA of Louisiana Commercial PPO 13.41 percent of total billed charges 8.68 13.41 Reimbursement at 85% of billed charges LACTATED RINGERS 1000ML J7120 HCPCS 260 RC 0338011704 NDC inpatient 1000 ML 28.64 14.32 BCBS Louisiana PPO 14.32 percent of total billed charges 14.32 24.34 50% of Eligible Charges LACTATED RINGERS 1000ML J7120 HCPCS 260 RC 0338011704 NDC outpatient 1000 ML 28.64 22.91 BCBS Louisiana PPO 22.91 percent of total billed charges 15.75 24.34 80% of billed charge LACTATED RINGERS 1000ML J7120 HCPCS 260 RC 0338011704 NDC outpatient 1000 ML 28.64 22.91 Cigna Commercial PPO 15.75 percent of total billed charges 15.75 24.34 55% of Billed Charges LACTATED RINGERS 1000ML J7120 HCPCS 260 RC 0338011704 NDC inpatient 1000 ML 28.64 14.32 IMA of Louisiana Commercial PPO 24.34 percent of total billed charges 14.32 24.34 Inpatient Reimbursement at 85% of Billed Charges LACTATED RINGERS 1000ML J7120 HCPCS 260 RC 0338011704 NDC outpatient 1000 ML 28.64 22.91 IMA of Louisiana Commercial PPO 24.34 percent of total billed charges 15.75 24.34 Reimbursement at 85% of billed charges CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC inpatient 25 ME 1.3 0.65 BCBS Louisiana PPO 0.65 percent of total billed charges 0.65 1.11 50% of Eligible Charges CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC outpatient 25 ME 1.3 1.04 BCBS Louisiana PPO 1.04 percent of total billed charges 0.72 1.11 80% of billed charge CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC outpatient 25 ME 1.3 1.04 Cigna Commercial PPO 0.72 percent of total billed charges 0.72 1.11 55% of Billed Charges CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC inpatient 25 ME 1.3 0.65 IMA of Louisiana Commercial PPO 1.11 percent of total billed charges 0.65 1.11 Inpatient Reimbursement at 85% of Billed Charges CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC outpatient 25 ME 1.3 1.04 IMA of Louisiana Commercial PPO 1.11 percent of total billed charges 0.72 1.11 Reimbursement at 85% of billed charges CHLORDIAZEPOXIDE 25MG CAP NON-FORM 250 RC 0555015902 NDC outpatient 25 ME 1.3 1.04 Aetna Commercial PPO 0.72 percent of total billed charges 0.72 1.11 55 of billed Charges BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BUPROPION HCL SR 100MG TABLET 250 RC 4354728810 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ACETAMINOPHEN 1000MG/100ML IV J0131 HCPCS 260 RC 0781927495 NDC inpatient 1000 ME 20.95 10.48 BCBS Louisiana PPO 10.48 percent of total billed charges 10.48 17.81 50% of Eligible Charges ACETAMINOPHEN 1000MG/100ML IV J0131 HCPCS 260 RC 0781927495 NDC outpatient 1000 ME 20.95 16.76 BCBS Louisiana PPO 16.76 percent of total billed charges 11.52 17.81 80% of billed charge ACETAMINOPHEN 1000MG/100ML IV J0131 HCPCS 260 RC 0781927495 NDC outpatient 1000 ME 20.95 16.76 Cigna Commercial PPO 11.52 percent of total billed charges 11.52 17.81 55% of Billed Charges ACETAMINOPHEN 1000MG/100ML IV J0131 HCPCS 260 RC 0781927495 NDC inpatient 1000 ME 20.95 10.48 IMA of Louisiana Commercial PPO 17.81 percent of total billed charges 10.48 17.81 Inpatient Reimbursement at 85% of Billed Charges ACETAMINOPHEN 1000MG/100ML IV J0131 HCPCS 260 RC 0781927495 NDC outpatient 1000 ME 20.95 16.76 IMA of Louisiana Commercial PPO 17.81 percent of total billed charges 11.52 17.81 Reimbursement at 85% of billed charges TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC inpatient 100 ME 5.7 2.85 BCBS Louisiana PPO 2.85 percent of total billed charges 2.85 4.85 50% of Eligible Charges TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC outpatient 100 ME 5.7 4.56 BCBS Louisiana PPO 4.56 percent of total billed charges 3.14 4.85 80% of billed charge TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC outpatient 100 ME 5.7 4.56 Cigna Commercial PPO 3.14 percent of total billed charges 3.14 4.85 55% of Billed Charges TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC inpatient 100 ME 5.7 2.85 IMA of Louisiana Commercial PPO 4.85 percent of total billed charges 2.85 4.85 Inpatient Reimbursement at 85% of Billed Charges TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC outpatient 100 ME 5.7 4.56 IMA of Louisiana Commercial PPO 4.85 percent of total billed charges 3.14 4.85 Reimbursement at 85% of billed charges TOBRAMYCIN 40MG/100ML IV NON -FORM 260 RC 6745747300 NDC outpatient 100 ME 5.7 4.56 Aetna Commercial PPO 3.14 percent of total billed charges 3.14 4.85 55 of billed Charges SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC inpatient 20 ML 8.1 4.05 BCBS Louisiana PPO 4.05 percent of total billed charges 4.05 6.89 50% of Eligible Charges SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC outpatient 20 ML 8.1 6.48 BCBS Louisiana PPO 6.48 percent of total billed charges 4.46 6.89 80% of billed charge SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC outpatient 20 ML 8.1 6.48 Cigna Commercial PPO 4.46 percent of total billed charges 4.46 6.89 55% of Billed Charges SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC inpatient 20 ML 8.1 4.05 IMA of Louisiana Commercial PPO 6.89 percent of total billed charges 4.05 6.89 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC outpatient 20 ML 8.1 6.48 IMA of Louisiana Commercial PPO 6.89 percent of total billed charges 4.46 6.89 Reimbursement at 85% of billed charges SODIUM CHL 0.9% 20ML PF 250 RC 0409488810 NDC outpatient 20 ML 8.1 6.48 Aetna Commercial PPO 4.46 percent of total billed charges 4.46 6.89 55 of billed Charges MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC inpatient 1 GR 112.48 56.24 BCBS Louisiana PPO 56.24 percent of total billed charges 56.24 95.61 50% of Eligible Charges MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC outpatient 1 GR 112.48 89.98 BCBS Louisiana PPO 89.98 percent of total billed charges 61.86 95.61 80% of billed charge MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC outpatient 1 GR 112.48 89.98 Cigna Commercial PPO 61.86 percent of total billed charges 61.86 95.61 55% of Billed Charges MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC inpatient 1 GR 112.48 56.24 IMA of Louisiana Commercial PPO 95.61 percent of total billed charges 56.24 95.61 Inpatient Reimbursement at 85% of Billed Charges MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC outpatient 1 GR 112.48 89.98 IMA of Louisiana Commercial PPO 95.61 percent of total billed charges 61.86 95.61 Reimbursement at 85% of billed charges MEROPENEM 1GM IVPB NON-FORMULARY 260 RC 0264318511 NDC outpatient 1 GR 112.48 89.98 Aetna Commercial PPO 61.86 percent of total billed charges 61.86 95.61 55 of billed Charges TRACTION MECHANICAL 97012 CPT 421 RC inpatient 37.55 18.78 BCBS Louisiana PPO 18.78 percent of total billed charges 18.78 31.92 50% of Eligible Charges TRACTION MECHANICAL 97012 CPT 421 RC outpatient 37.55 30.04 BCBS Louisiana PPO 30.04 percent of total billed charges 30.04 85 80% of billed charge TRACTION MECHANICAL 97012 CPT 421 RC outpatient 37.55 30.04 Cigna Commercial PPO 85 other 30.04 85 63% of Billed Charges TRACTION MECHANICAL 97012 CPT 421 RC inpatient 37.55 18.78 IMA of Louisiana Commercial PPO 31.92 percent of total billed charges 18.78 31.92 Inpatient Reimbursement at 85% of Billed Charges TRACTION MECHANICAL 97012 CPT 421 RC outpatient 37.55 30.04 IMA of Louisiana Commercial PPO 31.92 percent of total billed charges 30.04 85 Reimbursement at 85% of billed charges TRACTION MECHANICAL 97012 CPT 421 RC outpatient 37.55 30.04 Aetna Commercial PPO 30.84 fee schedule 30.04 85 200% Of Aetna Market Fee Schedule ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC inpatient 10652.2 5326.1 BCBS Louisiana PPO 5326.1 percent of total billed charges 5326.1 9054.37 50% of Eligible Charges ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC outpatient 10652.2 8521.76 BCBS Louisiana PPO 8521.76 percent of total billed charges 1300 9054.37 80% of billed charges ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC outpatient 10652.2 8521.76 Cigna Commercial PPO 5858.71 percent of total billed charges 1300 9054.37 55% of Billed Charges ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC inpatient 10652.2 5326.1 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 5326.1 9054.37 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC outpatient 10652.2 8521.76 IMA of Louisiana Commercial PPO 9054.37 percent of total billed charges 1300 9054.37 Reimbursement at 85% of billed charges ARTHROSCOPY ROTATOR CUFF REPR 29827 CPT 360 RC outpatient 10652.2 8521.76 Aetna Commercial PPO 1300 fee schedule 1300 9054.37 Case Rate ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC inpatient 4430.75 2215.38 BCBS Louisiana PPO 2215.38 percent of total billed charges 2215.38 3766.14 50% of Eligible Charges ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC outpatient 4430.75 3544.6 BCBS Louisiana PPO 3544.6 percent of total billed charges 1300 3766.14 80% of billed charges ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC outpatient 4430.75 3544.6 Cigna Commercial PPO 2436.91 percent of total billed charges 1300 3766.14 55% of Billed Charges ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC inpatient 4430.75 2215.38 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 2215.38 3766.14 Inpatient Reimbursement at 85% of Billed Charges ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC outpatient 4430.75 3544.6 IMA of Louisiana Commercial PPO 3766.14 percent of total billed charges 1300 3766.14 Reimbursement at 85% of billed charges ANKLE ARTHROSCOPY/SURGERY 29891 CPT 360 RC outpatient 4430.75 3544.6 Aetna Commercial PPO 1300 fee schedule 1300 3766.14 Case Rate VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC inpatient 1531.43 765.72 BCBS Louisiana PPO 765.72 percent of total billed charges 765.72 1301.72 50% of Eligible Charges VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC outpatient 1531.43 1225.14 BCBS Louisiana PPO 1225.14 percent of total billed charges 842.29 1301.72 80% of billed charges VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC outpatient 1531.43 1225.14 Cigna Commercial PPO 842.29 percent of total billed charges 842.29 1301.72 55% of Billed Charges VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC inpatient 1531.43 765.72 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 765.72 1301.72 Inpatient Reimbursement at 85% of Billed Charges VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC outpatient 1531.43 1225.14 IMA of Louisiana Commercial PPO 1301.72 percent of total billed charges 842.29 1301.72 Reimbursement at 85% of billed charges VASCULAR SURGERY PROCEDURE 37799 CPT 360 RC outpatient 1531.43 1225.14 Aetna Commercial PPO 1300 fee schedule 842.29 1301.72 Case Rate IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges IMPLANT SPINAL CANAL CATH 62350 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC inpatient 34936.7 17468.35 BCBS Louisiana PPO 17468.35 percent of total billed charges 17468.35 29696.2 50% of Eligible Charges IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC outpatient 34936.7 27949.36 BCBS Louisiana PPO 27949.36 percent of total billed charges 1300 29696.2 80% of billed charges IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC outpatient 34936.7 27949.36 Cigna Commercial PPO 19215.19 percent of total billed charges 1300 29696.2 55% of Billed Charges IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC inpatient 34936.7 17468.35 IMA of Louisiana Commercial PPO 29696.2 percent of total billed charges 17468.35 29696.2 Inpatient Reimbursement at 85% of Billed Charges IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC outpatient 34936.7 27949.36 IMA of Louisiana Commercial PPO 29696.2 percent of total billed charges 1300 29696.2 Reimbursement at 85% of billed charges IMPLANT SPINE INFUSION PUMP 62361 CPT 360 RC outpatient 34936.7 27949.36 Aetna Commercial PPO 1300 fee schedule 1300 29696.2 Case Rate "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC inpatient 611.75 305.88 BCBS Louisiana PPO 305.88 percent of total billed charges 305.88 519.99 50% of Eligible Charges "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC outpatient 611.75 489.4 BCBS Louisiana PPO 489.4 percent of total billed charges 336.46 1300 80% of billed charges "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC outpatient 611.75 489.4 Cigna Commercial PPO 336.46 percent of total billed charges 336.46 1300 55% of Billed Charges "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC inpatient 611.75 305.88 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 305.88 519.99 Inpatient Reimbursement at 85% of Billed Charges "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC outpatient 611.75 489.4 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 336.46 1300 Reimbursement at 85% of billed charges "NBLOCK INJ, OCCIPITAL" 64405 CPT 360 RC outpatient 611.75 489.4 Aetna Commercial PPO 1300 fee schedule 336.46 1300 Case Rate DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC inpatient 3686.8 1843.4 BCBS Louisiana PPO 1843.4 percent of total billed charges 1843.4 3133.78 50% of Eligible Charges DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC outpatient 3686.8 2949.44 BCBS Louisiana PPO 2949.44 percent of total billed charges 1300 3133.78 80% of billed charges DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC outpatient 3686.8 2949.44 Cigna Commercial PPO 2027.74 percent of total billed charges 1300 3133.78 55% of Billed Charges DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC inpatient 3686.8 1843.4 IMA of Louisiana Commercial PPO 3133.78 percent of total billed charges 1843.4 3133.78 Inpatient Reimbursement at 85% of Billed Charges DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC outpatient 3686.8 2949.44 IMA of Louisiana Commercial PPO 3133.78 percent of total billed charges 1300 3133.78 Reimbursement at 85% of billed charges DESTR PARAVERTEBRL NERVE L/S 64633 CPT 360 RC outpatient 3686.8 2949.44 Aetna Commercial PPO 1300 fee schedule 1300 3133.78 Case Rate REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges REMOVE SPINE INFUSION DEVICE 62365 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC inpatient 7198.45 3599.23 BCBS Louisiana PPO 3599.23 percent of total billed charges 3599.23 6118.68 50% of Eligible Charges REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC outpatient 7198.45 5758.76 BCBS Louisiana PPO 5758.76 percent of total billed charges 1300 6118.68 80% of billed charges REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC outpatient 7198.45 5758.76 Cigna Commercial PPO 3959.15 percent of total billed charges 1300 6118.68 55% of Billed Charges REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC inpatient 7198.45 3599.23 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 3599.23 6118.68 Inpatient Reimbursement at 85% of Billed Charges REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC outpatient 7198.45 5758.76 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 1300 6118.68 Reimbursement at 85% of billed charges REVISE REMOVE NEURORECEIVER 63688 CPT 360 RC outpatient 7198.45 5758.76 Aetna Commercial PPO 1300 fee schedule 1300 6118.68 Case Rate SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges SHOULDER ARTHROSCOPY REMOVAL FOREIGN BOD 29819 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC inpatient 611.75 305.88 BCBS Louisiana PPO 305.88 percent of total billed charges 305.88 519.99 50% of Eligible Charges NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC outpatient 611.75 489.4 BCBS Louisiana PPO 489.4 percent of total billed charges 336.46 1300 80% of billed charges NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC outpatient 611.75 489.4 Cigna Commercial PPO 336.46 percent of total billed charges 336.46 1300 55% of Billed Charges NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC inpatient 611.75 305.88 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 305.88 519.99 Inpatient Reimbursement at 85% of Billed Charges NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC outpatient 611.75 489.4 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 336.46 1300 Reimbursement at 85% of billed charges NJX ANES AND STEROID PLANTAR COMMON DIGI 64455 CPT 360 RC outpatient 611.75 489.4 Aetna Commercial PPO 1300 fee schedule 336.46 1300 Case Rate LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC inpatient 50 UN 1.8 0.9 BCBS Louisiana PPO 0.9 percent of total billed charges 0.9 1.53 50% of Eligible Charges LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC outpatient 50 UN 1.8 1.44 BCBS Louisiana PPO 1.44 percent of total billed charges 0.99 1.53 80% of billed charge LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC outpatient 50 UN 1.8 1.44 Cigna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55% of Billed Charges LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC inpatient 50 UN 1.8 0.9 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.9 1.53 Inpatient Reimbursement at 85% of Billed Charges LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC outpatient 50 UN 1.8 1.44 IMA of Louisiana Commercial PPO 1.53 percent of total billed charges 0.99 1.53 Reimbursement at 85% of billed charges LEVOTHYROXINE 50MCG TABLET 250 RC 5107944020 NDC outpatient 50 UN 1.8 1.44 Aetna Commercial PPO 0.99 percent of total billed charges 0.99 1.53 55 of billed Charges VALSARTAN 160MG TABLET 250 RC 6068763411 NDC inpatient 160 ME 6.13 3.07 BCBS Louisiana PPO 3.07 percent of total billed charges 3.07 5.21 50% of Eligible Charges VALSARTAN 160MG TABLET 250 RC 6068763411 NDC outpatient 160 ME 6.13 4.9 BCBS Louisiana PPO 4.9 percent of total billed charges 3.37 5.21 80% of billed charge VALSARTAN 160MG TABLET 250 RC 6068763411 NDC outpatient 160 ME 6.13 4.9 Cigna Commercial PPO 3.37 percent of total billed charges 3.37 5.21 55% of Billed Charges VALSARTAN 160MG TABLET 250 RC 6068763411 NDC inpatient 160 ME 6.13 3.07 IMA of Louisiana Commercial PPO 5.21 percent of total billed charges 3.07 5.21 Inpatient Reimbursement at 85% of Billed Charges VALSARTAN 160MG TABLET 250 RC 6068763411 NDC outpatient 160 ME 6.13 4.9 IMA of Louisiana Commercial PPO 5.21 percent of total billed charges 3.37 5.21 Reimbursement at 85% of billed charges VALSARTAN 160MG TABLET 250 RC 6068763411 NDC outpatient 160 ME 6.13 4.9 Aetna Commercial PPO 3.37 percent of total billed charges 3.37 5.21 55 of billed Charges CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CETIRIZINE 10MG TAB NON-FORMULARY 250 RC 5107959701 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CITALOPRAM (CELEXA) 20MG TABLET 250 RC 0904608561 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC inpatient 10 ME 3.64 1.82 BCBS Louisiana PPO 1.82 percent of total billed charges 1.82 3.09 50% of Eligible Charges OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC outpatient 10 ME 3.64 2.91 BCBS Louisiana PPO 2.91 percent of total billed charges 2 3.09 80% of billed charge OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC outpatient 10 ME 3.64 2.91 Cigna Commercial PPO 2 percent of total billed charges 2 3.09 55% of Billed Charges OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC inpatient 10 ME 3.64 1.82 IMA of Louisiana Commercial PPO 3.09 percent of total billed charges 1.82 3.09 Inpatient Reimbursement at 85% of Billed Charges OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC outpatient 10 ME 3.64 2.91 IMA of Louisiana Commercial PPO 3.09 percent of total billed charges 2 3.09 Reimbursement at 85% of billed charges OXYCODONE IR 10MG TABLET 250 RC 0406851023 NDC outpatient 10 ME 3.64 2.91 Aetna Commercial PPO 2 percent of total billed charges 2 3.09 55 of billed Charges SERTRALINE 50MG TABLET 250 RC 6068724201 NDC inpatient 50 ME 1.65 0.83 BCBS Louisiana PPO 0.83 percent of total billed charges 0.83 1.4 50% of Eligible Charges SERTRALINE 50MG TABLET 250 RC 6068724201 NDC outpatient 50 ME 1.65 1.32 BCBS Louisiana PPO 1.32 percent of total billed charges 0.91 1.4 80% of billed charge SERTRALINE 50MG TABLET 250 RC 6068724201 NDC outpatient 50 ME 1.65 1.32 Cigna Commercial PPO 0.91 percent of total billed charges 0.91 1.4 55% of Billed Charges SERTRALINE 50MG TABLET 250 RC 6068724201 NDC inpatient 50 ME 1.65 0.83 IMA of Louisiana Commercial PPO 1.4 percent of total billed charges 0.83 1.4 Inpatient Reimbursement at 85% of Billed Charges SERTRALINE 50MG TABLET 250 RC 6068724201 NDC outpatient 50 ME 1.65 1.32 IMA of Louisiana Commercial PPO 1.4 percent of total billed charges 0.91 1.4 Reimbursement at 85% of billed charges SERTRALINE 50MG TABLET 250 RC 6068724201 NDC outpatient 50 ME 1.65 1.32 Aetna Commercial PPO 0.91 percent of total billed charges 0.91 1.4 55 of billed Charges BACLOFEN 10MG TAB 250 RC 6373947910 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges BACLOFEN 10MG TAB 250 RC 6373947910 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge BACLOFEN 10MG TAB 250 RC 6373947910 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges BACLOFEN 10MG TAB 250 RC 6373947910 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges BACLOFEN 10MG TAB 250 RC 6373947910 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges BACLOFEN 10MG TAB 250 RC 6373947910 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC inpatient 1 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC outpatient 1 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC outpatient 1 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC inpatient 1 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC outpatient 1 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ESTRADIOL 1MG TABLET 250 RC 4280608801 NDC outpatient 1 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC inpatient 500 ME 9.21 4.61 BCBS Louisiana PPO 4.61 percent of total billed charges 4.61 7.83 50% of Eligible Charges VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC outpatient 500 ME 9.21 7.37 BCBS Louisiana PPO 7.37 percent of total billed charges 5.07 7.83 80% of billed charge VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC outpatient 500 ME 9.21 7.37 Cigna Commercial PPO 5.07 percent of total billed charges 5.07 7.83 55% of Billed Charges VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC inpatient 500 ME 9.21 4.61 IMA of Louisiana Commercial PPO 7.83 percent of total billed charges 4.61 7.83 Inpatient Reimbursement at 85% of Billed Charges VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC outpatient 500 ME 9.21 7.37 IMA of Louisiana Commercial PPO 7.83 percent of total billed charges 5.07 7.83 Reimbursement at 85% of billed charges VALACYCLOVIR 500MG TABLET 250 RC 6808421511 NDC outpatient 500 ME 9.21 7.37 Aetna Commercial PPO 5.07 percent of total billed charges 5.07 7.83 55 of billed Charges CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC inpatient 0.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC outpatient 0.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC outpatient 0.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC inpatient 0.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC outpatient 0.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges CLONAZEPAM 0.5MG TABLET 250 RC 6068754401 NDC outpatient 0.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges VESICARE 5MG TABLET 250 RC 2930032813 NDC inpatient 5 ME 1.73 0.87 BCBS Louisiana PPO 0.87 percent of total billed charges 0.87 1.47 50% of Eligible Charges VESICARE 5MG TABLET 250 RC 2930032813 NDC outpatient 5 ME 1.73 1.38 BCBS Louisiana PPO 1.38 percent of total billed charges 0.95 1.47 80% of billed charge VESICARE 5MG TABLET 250 RC 2930032813 NDC outpatient 5 ME 1.73 1.38 Cigna Commercial PPO 0.95 percent of total billed charges 0.95 1.47 55% of Billed Charges VESICARE 5MG TABLET 250 RC 2930032813 NDC inpatient 5 ME 1.73 0.87 IMA of Louisiana Commercial PPO 1.47 percent of total billed charges 0.87 1.47 Inpatient Reimbursement at 85% of Billed Charges VESICARE 5MG TABLET 250 RC 2930032813 NDC outpatient 5 ME 1.73 1.38 IMA of Louisiana Commercial PPO 1.47 percent of total billed charges 0.95 1.47 Reimbursement at 85% of billed charges VESICARE 5MG TABLET 250 RC 2930032813 NDC outpatient 5 ME 1.73 1.38 Aetna Commercial PPO 0.95 percent of total billed charges 0.95 1.47 55 of billed Charges LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC inpatient 10 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC outpatient 10 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC outpatient 10 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC inpatient 10 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC outpatient 10 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LISINOPRIL 10MG TABLET 250 RC 0904679861 NDC outpatient 10 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges FENTANYL INJ 50MCG/ML 5ML J3010 HCPCS 250 RC 6332380605 NDC inpatient 50 UN 11.88 5.94 BCBS Louisiana PPO 5.94 percent of total billed charges 5.94 10.1 50% of Eligible Charges FENTANYL INJ 50MCG/ML 5ML J3010 HCPCS 250 RC 6332380605 NDC outpatient 50 UN 11.88 9.5 BCBS Louisiana PPO 9.5 percent of total billed charges 6.53 10.1 80% of billed charge FENTANYL INJ 50MCG/ML 5ML J3010 HCPCS 250 RC 6332380605 NDC outpatient 50 UN 11.88 9.5 Cigna Commercial PPO 6.53 percent of total billed charges 6.53 10.1 55% of Billed Charges FENTANYL INJ 50MCG/ML 5ML J3010 HCPCS 250 RC 6332380605 NDC inpatient 50 UN 11.88 5.94 IMA of Louisiana Commercial PPO 10.1 percent of total billed charges 5.94 10.1 Inpatient Reimbursement at 85% of Billed Charges FENTANYL INJ 50MCG/ML 5ML J3010 HCPCS 250 RC 6332380605 NDC outpatient 50 UN 11.88 9.5 IMA of Louisiana Commercial PPO 10.1 percent of total billed charges 6.53 10.1 Reimbursement at 85% of billed charges NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC inpatient 1 GR 13.95 6.98 BCBS Louisiana PPO 6.98 percent of total billed charges 6.98 11.86 50% of Eligible Charges NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC outpatient 1 GR 13.95 11.16 BCBS Louisiana PPO 11.16 percent of total billed charges 7.67 11.86 80% of billed charge NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC outpatient 1 GR 13.95 11.16 Cigna Commercial PPO 7.67 percent of total billed charges 7.67 11.86 55% of Billed Charges NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC inpatient 1 GR 13.95 6.98 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 6.98 11.86 Inpatient Reimbursement at 85% of Billed Charges NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC outpatient 1 GR 13.95 11.16 IMA of Louisiana Commercial PPO 11.86 percent of total billed charges 7.67 11.86 Reimbursement at 85% of billed charges NITROGLYCERIN OINT 2% 1G 250 RC 0281032608 NDC outpatient 1 GR 13.95 11.16 Aetna Commercial PPO 7.67 percent of total billed charges 7.67 11.86 55 of billed Charges METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges METHIMAZOLE 5MG TABLET 250 RC 6068766901 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC inpatient 300 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC outpatient 300 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC outpatient 300 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC inpatient 300 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC outpatient 300 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LITHIUM CARB 300MG TABLET 250 RC 0054852825 NDC outpatient 300 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC inpatient 225 ME 7.5 3.75 BCBS Louisiana PPO 3.75 percent of total billed charges 3.75 6.38 50% of Eligible Charges PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC outpatient 225 ME 7.5 6 BCBS Louisiana PPO 6 percent of total billed charges 4.13 6.38 80% of billed charge PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC outpatient 225 ME 7.5 6 Cigna Commercial PPO 4.13 percent of total billed charges 4.13 6.38 55% of Billed Charges PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC inpatient 225 ME 7.5 3.75 IMA of Louisiana Commercial PPO 6.38 percent of total billed charges 3.75 6.38 Inpatient Reimbursement at 85% of Billed Charges PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC outpatient 225 ME 7.5 6 IMA of Louisiana Commercial PPO 6.38 percent of total billed charges 4.13 6.38 Reimbursement at 85% of billed charges PROPAFENONE HCL ER 225MG CAPSULE 250 RC 0832074060 NDC outpatient 225 ME 7.5 6 Aetna Commercial PPO 4.13 percent of total billed charges 4.13 6.38 55 of billed Charges TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC inpatient 5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC outpatient 5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC outpatient 5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC inpatient 5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC outpatient 5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges TERAZOSIN 5MG CAPSULE 250 RC 5974638506 NDC outpatient 5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC inpatient 5 ME 1.57 0.79 BCBS Louisiana PPO 0.79 percent of total billed charges 0.79 1.33 50% of Eligible Charges BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC outpatient 5 ME 1.57 1.26 BCBS Louisiana PPO 1.26 percent of total billed charges 0.86 1.33 80% of billed charge BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC outpatient 5 ME 1.57 1.26 Cigna Commercial PPO 0.86 percent of total billed charges 0.86 1.33 55% of Billed Charges BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC inpatient 5 ME 1.57 0.79 IMA of Louisiana Commercial PPO 1.33 percent of total billed charges 0.79 1.33 Inpatient Reimbursement at 85% of Billed Charges BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC outpatient 5 ME 1.57 1.26 IMA of Louisiana Commercial PPO 1.33 percent of total billed charges 0.86 1.33 Reimbursement at 85% of billed charges BISOPROLOL FUM 5MG TABLET 250 RC 5026812715 NDC outpatient 5 ME 1.57 1.26 Aetna Commercial PPO 0.86 percent of total billed charges 0.86 1.33 55 of billed Charges PIPERACILLIN/TAZOBACTAM 3.375GM IV J2543 HCPCS 250 RC 6050561574 NDC inpatient 3.375 GR 12.6 6.3 BCBS Louisiana PPO 6.3 percent of total billed charges 6.3 10.71 50% of Eligible Charges PIPERACILLIN/TAZOBACTAM 3.375GM IV J2543 HCPCS 250 RC 6050561574 NDC outpatient 3.375 GR 12.6 10.08 BCBS Louisiana PPO 10.08 percent of total billed charges 6.93 10.71 80% of billed charge PIPERACILLIN/TAZOBACTAM 3.375GM IV J2543 HCPCS 250 RC 6050561574 NDC outpatient 3.375 GR 12.6 10.08 Cigna Commercial PPO 6.93 percent of total billed charges 6.93 10.71 55% of Billed Charges PIPERACILLIN/TAZOBACTAM 3.375GM IV J2543 HCPCS 250 RC 6050561574 NDC inpatient 3.375 GR 12.6 6.3 IMA of Louisiana Commercial PPO 10.71 percent of total billed charges 6.3 10.71 Inpatient Reimbursement at 85% of Billed Charges PIPERACILLIN/TAZOBACTAM 3.375GM IV J2543 HCPCS 250 RC 6050561574 NDC outpatient 3.375 GR 12.6 10.08 IMA of Louisiana Commercial PPO 10.71 percent of total billed charges 6.93 10.71 Reimbursement at 85% of billed charges DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC inpatient 50 ME 10.8 5.4 BCBS Louisiana PPO 5.4 percent of total billed charges 5.4 9.18 50% of Eligible Charges DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC outpatient 50 ME 10.8 8.64 BCBS Louisiana PPO 8.64 percent of total billed charges 5.94 9.18 80% of billed charge DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC outpatient 50 ME 10.8 8.64 Cigna Commercial PPO 5.94 percent of total billed charges 5.94 9.18 55% of Billed Charges DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC inpatient 50 ME 10.8 5.4 IMA of Louisiana Commercial PPO 9.18 percent of total billed charges 5.4 9.18 Inpatient Reimbursement at 85% of Billed Charges DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC outpatient 50 ME 10.8 8.64 IMA of Louisiana Commercial PPO 9.18 percent of total billed charges 5.94 9.18 Reimbursement at 85% of billed charges DESVENLAFAXINE ER 50MG TABLET 250 RC 7288814330 NDC outpatient 50 ME 10.8 8.64 Aetna Commercial PPO 5.94 percent of total billed charges 5.94 9.18 55 of billed Charges EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC inpatient 0.1 ME 541.15 270.58 BCBS Louisiana PPO 270.58 percent of total billed charges 270.58 459.98 50% of Eligible Charges EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC outpatient 0.1 ME 541.15 432.92 BCBS Louisiana PPO 432.92 percent of total billed charges 297.63 459.98 80% of billed charge EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC outpatient 0.1 ME 541.15 432.92 Cigna Commercial PPO 297.63 percent of total billed charges 297.63 459.98 55% of Billed Charges EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC inpatient 0.1 ME 541.15 270.58 IMA of Louisiana Commercial PPO 459.98 percent of total billed charges 270.58 459.98 Inpatient Reimbursement at 85% of Billed Charges EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC outpatient 0.1 ME 541.15 432.92 IMA of Louisiana Commercial PPO 459.98 percent of total billed charges 297.63 459.98 Reimbursement at 85% of billed charges EPINEPHRINE (ADRENALIN) INJ : 30MG/30ML 260 RC 4202316801 NDC outpatient 0.1 ME 541.15 432.92 Aetna Commercial PPO 297.63 percent of total billed charges 297.63 459.98 55 of billed Charges POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC inpatient 20 UN 23.5 11.75 BCBS Louisiana PPO 11.75 percent of total billed charges 11.75 19.98 50% of Eligible Charges POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC outpatient 20 UN 23.5 18.8 BCBS Louisiana PPO 18.8 percent of total billed charges 12.93 19.98 80% of billed charge POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC outpatient 20 UN 23.5 18.8 Cigna Commercial PPO 12.93 percent of total billed charges 12.93 19.98 55% of Billed Charges POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC inpatient 20 UN 23.5 11.75 IMA of Louisiana Commercial PPO 19.98 percent of total billed charges 11.75 19.98 Inpatient Reimbursement at 85% of Billed Charges POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC outpatient 20 UN 23.5 18.8 IMA of Louisiana Commercial PPO 19.98 percent of total billed charges 12.93 19.98 Reimbursement at 85% of billed charges POTASSIUM CHL 20MEQ IV 100ML 260 RC 0409665106 NDC outpatient 20 UN 23.5 18.8 Aetna Commercial PPO 12.93 percent of total billed charges 12.93 19.98 55 of billed Charges VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC inpatient 75 ME 4.63 2.32 BCBS Louisiana PPO 2.32 percent of total billed charges 2.32 3.94 50% of Eligible Charges VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC outpatient 75 ME 4.63 3.7 BCBS Louisiana PPO 3.7 percent of total billed charges 2.55 3.94 80% of billed charge VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC outpatient 75 ME 4.63 3.7 Cigna Commercial PPO 2.55 percent of total billed charges 2.55 3.94 55% of Billed Charges VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC inpatient 75 ME 4.63 2.32 IMA of Louisiana Commercial PPO 3.94 percent of total billed charges 2.32 3.94 Inpatient Reimbursement at 85% of Billed Charges VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC outpatient 75 ME 4.63 3.7 IMA of Louisiana Commercial PPO 3.94 percent of total billed charges 2.55 3.94 Reimbursement at 85% of billed charges VENLAFAXINE HCL 75MG TAB 250 RC 6808485601 NDC outpatient 75 ME 4.63 3.7 Aetna Commercial PPO 2.55 percent of total billed charges 2.55 3.94 55 of billed Charges MEPERIDINE 25MG/ML 1ML J8499 HCPCS 250 RC 0641605225 NDC inpatient 12.5 ME 13.85 6.93 BCBS Louisiana PPO 6.93 percent of total billed charges 6.93 11.77 50% of Eligible Charges MEPERIDINE 25MG/ML 1ML J8499 HCPCS 250 RC 0641605225 NDC outpatient 12.5 ME 13.85 11.08 BCBS Louisiana PPO 11.08 percent of total billed charges 7.62 11.77 80% of billed charge MEPERIDINE 25MG/ML 1ML J8499 HCPCS 250 RC 0641605225 NDC outpatient 12.5 ME 13.85 11.08 Cigna Commercial PPO 7.62 percent of total billed charges 7.62 11.77 55% of Billed Charges MEPERIDINE 25MG/ML 1ML J8499 HCPCS 250 RC 0641605225 NDC inpatient 12.5 ME 13.85 6.93 IMA of Louisiana Commercial PPO 11.77 percent of total billed charges 6.93 11.77 Inpatient Reimbursement at 85% of Billed Charges MEPERIDINE 25MG/ML 1ML J8499 HCPCS 250 RC 0641605225 NDC outpatient 12.5 ME 13.85 11.08 IMA of Louisiana Commercial PPO 11.77 percent of total billed charges 7.62 11.77 Reimbursement at 85% of billed charges ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC inpatient 2.5 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC outpatient 2.5 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC outpatient 2.5 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC inpatient 2.5 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC outpatient 2.5 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges ENALAPRIL 2.5MG TABLET 250 RC 6868271001 NDC outpatient 2.5 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges ESTRADIOL PATCH 0.1MG NON-FORMULARY J8499 HCPCS 250 RC 5041945204 NDC inpatient 0.1 ME 48.78 24.39 BCBS Louisiana PPO 24.39 percent of total billed charges 24.39 41.46 50% of Eligible Charges ESTRADIOL PATCH 0.1MG NON-FORMULARY J8499 HCPCS 250 RC 5041945204 NDC outpatient 0.1 ME 48.78 39.02 BCBS Louisiana PPO 39.02 percent of total billed charges 26.83 41.46 80% of billed charge ESTRADIOL PATCH 0.1MG NON-FORMULARY J8499 HCPCS 250 RC 5041945204 NDC outpatient 0.1 ME 48.78 39.02 Cigna Commercial PPO 26.83 percent of total billed charges 26.83 41.46 55% of Billed Charges ESTRADIOL PATCH 0.1MG NON-FORMULARY J8499 HCPCS 250 RC 5041945204 NDC inpatient 0.1 ME 48.78 24.39 IMA of Louisiana Commercial PPO 41.46 percent of total billed charges 24.39 41.46 Inpatient Reimbursement at 85% of Billed Charges ESTRADIOL PATCH 0.1MG NON-FORMULARY J8499 HCPCS 250 RC 5041945204 NDC outpatient 0.1 ME 48.78 39.02 IMA of Louisiana Commercial PPO 41.46 percent of total billed charges 26.83 41.46 Reimbursement at 85% of billed charges HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC inpatient 10 ME 3.84 1.92 BCBS Louisiana PPO 1.92 percent of total billed charges 1.92 3.26 50% of Eligible Charges HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC outpatient 10 ME 3.84 3.07 BCBS Louisiana PPO 3.07 percent of total billed charges 2.11 3.26 80% of billed charge HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC outpatient 10 ME 3.84 3.07 Cigna Commercial PPO 2.11 percent of total billed charges 2.11 3.26 55% of Billed Charges HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC inpatient 10 ME 3.84 1.92 IMA of Louisiana Commercial PPO 3.26 percent of total billed charges 1.92 3.26 Inpatient Reimbursement at 85% of Billed Charges HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC outpatient 10 ME 3.84 3.07 IMA of Louisiana Commercial PPO 3.26 percent of total billed charges 2.11 3.26 Reimbursement at 85% of billed charges HYDRALAZINE 10MG TAB NON-FORMULARY 250 RC 0037390400 NDC outpatient 10 ME 3.84 3.07 Aetna Commercial PPO 2.11 percent of total billed charges 2.11 3.26 55 of billed Charges ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC inpatient 0.5 ME 1.5 0.75 BCBS Louisiana PPO 0.75 percent of total billed charges 0.75 1.28 50% of Eligible Charges ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC outpatient 0.5 ME 1.5 1.2 BCBS Louisiana PPO 1.2 percent of total billed charges 0.83 1.28 80% of billed charge ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC outpatient 0.5 ME 1.5 1.2 Cigna Commercial PPO 0.83 percent of total billed charges 0.83 1.28 55% of Billed Charges ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC inpatient 0.5 ME 1.5 0.75 IMA of Louisiana Commercial PPO 1.28 percent of total billed charges 0.75 1.28 Inpatient Reimbursement at 85% of Billed Charges ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC outpatient 0.5 ME 1.5 1.2 IMA of Louisiana Commercial PPO 1.28 percent of total billed charges 0.83 1.28 Reimbursement at 85% of billed charges ALPRAZOLAM 0.5MG TABLET 250 RC 6068738801 NDC outpatient 0.5 ME 1.5 1.2 Aetna Commercial PPO 0.83 percent of total billed charges 0.83 1.28 55 of billed Charges PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC inpatient 100 ME 1.75 0.88 BCBS Louisiana PPO 0.88 percent of total billed charges 0.88 1.49 50% of Eligible Charges PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC outpatient 100 ME 1.75 1.4 BCBS Louisiana PPO 1.4 percent of total billed charges 0.96 1.49 80% of billed charge PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC outpatient 100 ME 1.75 1.4 Cigna Commercial PPO 0.96 percent of total billed charges 0.96 1.49 55% of Billed Charges PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC inpatient 100 ME 1.75 0.88 IMA of Louisiana Commercial PPO 1.49 percent of total billed charges 0.88 1.49 Inpatient Reimbursement at 85% of Billed Charges PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC outpatient 100 ME 1.75 1.4 IMA of Louisiana Commercial PPO 1.49 percent of total billed charges 0.96 1.49 Reimbursement at 85% of billed charges PHENAZOPYRIDINE 100MG TABLET 250 RC 6516268110 NDC outpatient 100 ME 1.75 1.4 Aetna Commercial PPO 0.96 percent of total billed charges 0.96 1.49 55 of billed Charges LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC inpatient 100 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC outpatient 100 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC outpatient 100 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC inpatient 100 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC outpatient 100 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges LAMOTRIGINE 100MG TABLET 250 RC 2930011201 NDC outpatient 100 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges DIVIGEL 1GM GEL NON-FORMULARY J8499 HCPCS 250 RC 0051102858 NDC inpatient 1 GR 296.8 148.4 BCBS Louisiana PPO 148.4 percent of total billed charges 148.4 252.28 50% of Eligible Charges DIVIGEL 1GM GEL NON-FORMULARY J8499 HCPCS 250 RC 0051102858 NDC outpatient 1 GR 296.8 237.44 BCBS Louisiana PPO 237.44 percent of total billed charges 163.24 252.28 80% of billed charge DIVIGEL 1GM GEL NON-FORMULARY J8499 HCPCS 250 RC 0051102858 NDC outpatient 1 GR 296.8 237.44 Cigna Commercial PPO 163.24 percent of total billed charges 163.24 252.28 55% of Billed Charges DIVIGEL 1GM GEL NON-FORMULARY J8499 HCPCS 250 RC 0051102858 NDC inpatient 1 GR 296.8 148.4 IMA of Louisiana Commercial PPO 252.28 percent of total billed charges 148.4 252.28 Inpatient Reimbursement at 85% of Billed Charges DIVIGEL 1GM GEL NON-FORMULARY J8499 HCPCS 250 RC 0051102858 NDC outpatient 1 GR 296.8 237.44 IMA of Louisiana Commercial PPO 252.28 percent of total billed charges 163.24 252.28 Reimbursement at 85% of billed charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC inpatient 15139.03 7569.52 BCBS Louisiana PPO 7569.52 percent of total billed charges 7569.52 12868.18 50% of Eligible Charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC outpatient 15139.03 12111.22 BCBS Louisiana PPO 12111.22 percent of total billed charges 1300 12868.18 80% of billed charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC outpatient 15139.03 12111.22 Cigna Commercial PPO 8326.47 percent of total billed charges 1300 12868.18 55% of Billed Charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC inpatient 15139.03 7569.52 IMA of Louisiana Commercial PPO 12868.18 percent of total billed charges 7569.52 12868.18 Inpatient Reimbursement at 85% of Billed Charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC outpatient 15139.03 12111.22 IMA of Louisiana Commercial PPO 12868.18 percent of total billed charges 1300 12868.18 Reimbursement at 85% of billed charges REVJ INCL RPLCMT NSTIM ELTRD PRQ RA FLOU 63663 CPT 360 RC outpatient 15139.03 12111.22 Aetna Commercial PPO 1300 fee schedule 1300 12868.18 Case Rate SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges SPINAL PUNCT THER DARAIN CEREB FLUID 62272 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 100 11913.64 6800 case rate LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges LAM EXC ISPI LES OT/TH NEO IDRL LMBR 63272 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC inpatient 2975.88 1487.94 BCBS Louisiana PPO 1487.94 percent of total billed charges 1487.94 2529.5 50% of Eligible Charges ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC outpatient 2975.88 2380.7 BCBS Louisiana PPO 2380.7 percent of total billed charges 1300 2529.5 80% of billed charges ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC outpatient 2975.88 2380.7 Cigna Commercial PPO 1636.73 percent of total billed charges 1300 2529.5 55% of Billed Charges ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC inpatient 2975.88 1487.94 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1487.94 2529.5 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC outpatient 2975.88 2380.7 IMA of Louisiana Commercial PPO 2529.5 percent of total billed charges 1300 2529.5 Reimbursement at 85% of billed charges ARTHROSCOPY WRIST DIAG+SYNOCIAL BX SPX 29840 CPT 360 RC outpatient 2975.88 2380.7 Aetna Commercial PPO 1300 fee schedule 1300 2529.5 Case Rate REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC inpatient 10662.4 5331.2 BCBS Louisiana PPO 5331.2 percent of total billed charges 5331.2 9063.04 50% of Eligible Charges REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC outpatient 10662.4 8529.92 BCBS Louisiana PPO 8529.92 percent of total billed charges 1300 9063.04 80% of billed charges REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC outpatient 10662.4 8529.92 Cigna Commercial PPO 5864.32 percent of total billed charges 1300 9063.04 55% of Billed Charges REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC inpatient 10662.4 5331.2 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 5331.2 9063.04 Inpatient Reimbursement at 85% of Billed Charges REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC outpatient 10662.4 8529.92 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 1300 9063.04 Reimbursement at 85% of billed charges REP BLOOD VESS DIRECT NECK 35201 CPT 360 RC outpatient 10662.4 8529.92 Aetna Commercial PPO 1300 fee schedule 1300 9063.04 Case Rate PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC inpatient 403.62 201.81 BCBS Louisiana PPO 201.81 percent of total billed charges 201.81 343.08 50% of Eligible Charges PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC outpatient 403.62 322.9 BCBS Louisiana PPO 322.9 percent of total billed charges 85 343.08 80% of billed charge PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC outpatient 403.62 322.9 Cigna Commercial PPO 85 other 85 343.08 63% of Billed Charges PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC inpatient 403.62 201.81 IMA of Louisiana Commercial PPO 343.08 percent of total billed charges 201.81 343.08 Inpatient Reimbursement at 85% of Billed Charges PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC outpatient 403.62 322.9 IMA of Louisiana Commercial PPO 343.08 percent of total billed charges 85 343.08 Reimbursement at 85% of billed charges PT WORK CONDITIONING INITIAL 2 HOURS 97545 CPT 421 RC outpatient 403.62 322.9 Aetna Commercial PPO 252.42 fee schedule 85 343.08 200% Of Aetna Market Fee Schedule PT UNLISTED MODALITY 97039 CPT 421 RC inpatient 45.26 22.63 BCBS Louisiana PPO 22.63 percent of total billed charges 22.63 38.47 50% of Eligible Charges PT UNLISTED MODALITY 97039 CPT 421 RC outpatient 45.26 36.21 BCBS Louisiana PPO 36.21 percent of total billed charges 24.89 85 80% of billed charge PT UNLISTED MODALITY 97039 CPT 421 RC outpatient 45.26 36.21 Cigna Commercial PPO 85 other 24.89 85 63% of Billed Charges PT UNLISTED MODALITY 97039 CPT 421 RC inpatient 45.26 22.63 IMA of Louisiana Commercial PPO 38.47 percent of total billed charges 22.63 38.47 Inpatient Reimbursement at 85% of Billed Charges PT UNLISTED MODALITY 97039 CPT 421 RC outpatient 45.26 36.21 IMA of Louisiana Commercial PPO 38.47 percent of total billed charges 24.89 85 Reimbursement at 85% of billed charges PT UNLISTED MODALITY 97039 CPT 421 RC outpatient 45.26 36.21 Aetna Commercial PPO 24.89 percent of total billed charges 24.89 85 55 of billed Charges PT SHARPS DEBRIDEMENT 97597 CPT 421 RC inpatient 422.38 211.19 BCBS Louisiana PPO 211.19 percent of total billed charges 211.19 359.02 50% of Eligible Charges PT SHARPS DEBRIDEMENT 97597 CPT 421 RC outpatient 422.38 337.9 BCBS Louisiana PPO 337.9 percent of total billed charges 85 359.02 80% of billed charge PT SHARPS DEBRIDEMENT 97597 CPT 421 RC outpatient 422.38 337.9 Cigna Commercial PPO 85 other 85 359.02 63% of Billed Charges PT SHARPS DEBRIDEMENT 97597 CPT 421 RC inpatient 422.38 211.19 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 211.19 359.02 Inpatient Reimbursement at 85% of Billed Charges PT SHARPS DEBRIDEMENT 97597 CPT 421 RC outpatient 422.38 337.9 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 85 359.02 Reimbursement at 85% of billed charges PT SHARPS DEBRIDEMENT 97597 CPT 421 RC outpatient 422.38 337.9 Aetna Commercial PPO 232.31 percent of total billed charges 85 359.02 55 of billed Charges APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC inpatient 52.22 26.11 BCBS Louisiana PPO 26.11 percent of total billed charges 26.11 44.39 50% of Eligible Charges APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC outpatient 52.22 41.78 BCBS Louisiana PPO 41.78 percent of total billed charges 41.78 85 80% of billed charge APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC outpatient 52.22 41.78 Cigna Commercial PPO 85 other 41.78 85 63% of Billed Charges APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC inpatient 52.22 26.11 IMA of Louisiana Commercial PPO 44.39 percent of total billed charges 26.11 44.39 Inpatient Reimbursement at 85% of Billed Charges APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC outpatient 52.22 41.78 IMA of Louisiana Commercial PPO 44.39 percent of total billed charges 41.78 85 Reimbursement at 85% of billed charges APPL MODALITY 1+ AREAS WP 97022 CPT 421 RC outpatient 52.22 41.78 Aetna Commercial PPO 43.52 fee schedule 41.78 85 200% Of Aetna Market Fee Schedule LIG/BX TEMPORAL ART 37609 CPT 360 RC inpatient 3370.08 1685.04 BCBS Louisiana PPO 1685.04 percent of total billed charges 1685.04 2864.57 50% of Eligible Charges LIG/BX TEMPORAL ART 37609 CPT 360 RC outpatient 3370.08 2696.06 BCBS Louisiana PPO 2696.06 percent of total billed charges 1300 2864.57 80% of billed charges LIG/BX TEMPORAL ART 37609 CPT 360 RC outpatient 3370.08 2696.06 Cigna Commercial PPO 1853.54 percent of total billed charges 1300 2864.57 55% of Billed Charges LIG/BX TEMPORAL ART 37609 CPT 360 RC inpatient 3370.08 1685.04 IMA of Louisiana Commercial PPO 2864.57 percent of total billed charges 1685.04 2864.57 Inpatient Reimbursement at 85% of Billed Charges LIG/BX TEMPORAL ART 37609 CPT 360 RC outpatient 3370.08 2696.06 IMA of Louisiana Commercial PPO 2864.57 percent of total billed charges 1300 2864.57 Reimbursement at 85% of billed charges LIG/BX TEMPORAL ART 37609 CPT 360 RC outpatient 3370.08 2696.06 Aetna Commercial PPO 1300 fee schedule 1300 2864.57 Case Rate SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges SUTURE 1 NERVE MED MOTOR THENAR 64835 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges RPLCMNT/REVJ CSF SHUNT VALVE/CATH SHUNT 62230 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC inpatient 5025.93 2512.97 BCBS Louisiana PPO 2512.97 percent of total billed charges 2512.97 4272.04 50% of Eligible Charges ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC outpatient 5025.93 4020.74 BCBS Louisiana PPO 4020.74 percent of total billed charges 1300 4272.04 80% of billed charges ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC outpatient 5025.93 4020.74 Cigna Commercial PPO 2764.26 percent of total billed charges 1300 4272.04 55% of Billed Charges ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC inpatient 5025.93 2512.97 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 2512.97 4272.04 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC outpatient 5025.93 4020.74 IMA of Louisiana Commercial PPO 4272.04 percent of total billed charges 1300 4272.04 Reimbursement at 85% of billed charges ARTHROSCOPY ELBO SX SYNOVECTOMY PARTIAL 29835 CPT 360 RC outpatient 5025.93 4020.74 Aetna Commercial PPO 1300 fee schedule 1300 4272.04 Case Rate REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC inpatient 7277.9 3638.95 BCBS Louisiana PPO 3638.95 percent of total billed charges 3638.95 6186.22 50% of Eligible Charges REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC outpatient 7277.9 5822.32 BCBS Louisiana PPO 5822.32 percent of total billed charges 1300 6186.22 80% of billed charges REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC outpatient 7277.9 5822.32 Cigna Commercial PPO 4002.85 percent of total billed charges 1300 6186.22 55% of Billed Charges REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC inpatient 7277.9 3638.95 IMA of Louisiana Commercial PPO 6186.22 percent of total billed charges 3638.95 6186.22 Inpatient Reimbursement at 85% of Billed Charges REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC outpatient 7277.9 5822.32 IMA of Louisiana Commercial PPO 6186.22 percent of total billed charges 1300 6186.22 Reimbursement at 85% of billed charges REMOVAL PERITONEAL FOREIGN BODY FROM CAV 49402 CPT 360 RC outpatient 7277.9 5822.32 Aetna Commercial PPO 1300 fee schedule 1300 6186.22 Case Rate Pvb thoracic single inj site 64461 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges Pvb thoracic single inj site 64461 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges Pvb thoracic single inj site 64461 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges Pvb thoracic single inj site 64461 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges Pvb thoracic single inj site 64461 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges Pvb thoracic single inj site 64461 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 100 11913.64 6800 case rate BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges BX/EXC XDRL/IDRL LSN ANY LVL 63290 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges XRAY DX FLOURO GUIDANCE 77003 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT FOOT 3 VIEWS 73630 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT HAND 3 VIEWS 73130 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC inpatient 530 265 BCBS Louisiana PPO 265 percent of total billed charges 265 450.5 50% of Eligible Charges XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 BCBS Louisiana PPO 424 percent of total billed charges 291.5 450.5 80% of billed charge XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 Cigna Commercial PPO 291.5 percent of total billed charges 291.5 450.5 55% of Billed Charges XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC inpatient 530 265 IMA of Louisiana Commercial PPO 450.5 percent of total billed charges 265 450.5 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 IMA of Louisiana Commercial PPO 450.5 percent of total billed charges 291.5 450.5 Reimbursement at 85% of billed charges XRAY DX RT HIP OPERTVE OVR 73530 CPT 320 RC outpatient 530 424 Aetna Commercial PPO 291.5 percent of total billed charges 291.5 450.5 55 of billed Charges XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC inpatient 235 117.5 BCBS Louisiana PPO 117.5 percent of total billed charges 117.5 199.75 50% of Eligible Charges XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 BCBS Louisiana PPO 188 percent of total billed charges 129.25 199.75 80% of billed charge XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 Cigna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55% of Billed Charges XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC inpatient 235 117.5 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 117.5 199.75 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 129.25 199.75 Reimbursement at 85% of billed charges XRAY DX RT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 Aetna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55 of billed Charges XRAY DX RT SCAPULA 73010 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX RT SCAPULA 73010 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX RT SCAPULA 73010 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX RT SCAPULA 73010 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT SCAPULA 73010 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX RT SCAPULA 73010 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC inpatient 580.78 290.39 BCBS Louisiana PPO 290.39 percent of total billed charges 290.39 493.66 50% of Eligible Charges C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC outpatient 580.78 406.55 BCBS Louisiana PPO 406.55 percent of total billed charges 319.43 700 70% of billed charges C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC outpatient 580.78 406.55 Cigna Commercial PPO 319.43 percent of total billed charges 319.43 700 55% of Billed Charges C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC inpatient 580.78 290.39 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 290.39 493.66 Inpatient Reimbursement at 85% of Billed Charges C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC outpatient 580.78 406.55 IMA of Louisiana Commercial PPO 493.66 percent of total billed charges 319.43 700 Reimbursement at 85% of billed charges C-ARM FLUORO OTHER PAIN INJECTION 76000 CPT 320 RC outpatient 580.78 406.55 Aetna Commercial PPO 700 case rate 319.43 700 700 Per Code Per DOS Paid In Addition C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges C-ARM SPINE PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges X-RAY EXAM RT HIP UNI 1 VIEW 73501 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC inpatient 235 117.5 BCBS Louisiana PPO 117.5 percent of total billed charges 117.5 199.75 50% of Eligible Charges XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC outpatient 235 188 BCBS Louisiana PPO 188 percent of total billed charges 129.25 199.75 80% of billed charge XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC outpatient 235 188 Cigna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55% of Billed Charges XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC inpatient 235 117.5 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 117.5 199.75 Inpatient Reimbursement at 85% of Billed Charges XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC outpatient 235 188 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 129.25 199.75 Reimbursement at 85% of billed charges XRAY DX ABDOMEN 2 VIEW 74000 CPT 320 RC outpatient 235 188 Aetna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55 of billed Charges CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 200.31 700 70% of billed charges CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC outpatient 286.15 200.31 Cigna Commercial PPO 700 other 200.31 700 $700 Per Visit CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 200.31 700 Reimbursement at 85% of billed charges CT RIGHT UPPER EXTREMITY W/O CONTRAST 73200 CPT 352 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 200.31 700 700 Per Code Per DOS Paid In Addition CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT RIGHT UPPER EXTREMITY W/O & W/CONTRAS 73202 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges ULTRASOUND ABDOMEN COMPLETE 76700 CPT 402 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC inpatient 37.23 18.62 BCBS Louisiana PPO 18.62 percent of total billed charges 18.62 31.65 50% of Eligible Charges PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC outpatient 37.23 29.78 BCBS Louisiana PPO 29.78 percent of total billed charges 29.78 85 80% of billed charge PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC outpatient 37.23 29.78 Cigna Commercial PPO 85 other 29.78 85 63% of Billed Charges PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC inpatient 37.23 18.62 IMA of Louisiana Commercial PPO 31.65 percent of total billed charges 18.62 31.65 Inpatient Reimbursement at 85% of Billed Charges PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC outpatient 37.23 29.78 IMA of Louisiana Commercial PPO 31.65 percent of total billed charges 29.78 85 Reimbursement at 85% of billed charges PT ELECTRICAL STIMULATION (UNATTENDED) 97014 CPT 421 RC outpatient 37.23 29.78 Aetna Commercial PPO 30.26 fee schedule 29.78 85 200% Of Aetna Market Fee Schedule RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC inpatient 10 ME 82.02 41.01 BCBS Louisiana PPO 41.01 percent of total billed charges 41.01 69.72 50% of Eligible Charges RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC outpatient 10 ME 82.02 65.62 BCBS Louisiana PPO 65.62 percent of total billed charges 45.11 69.72 80% of billed charge RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC outpatient 10 ME 82.02 65.62 Cigna Commercial PPO 45.11 percent of total billed charges 45.11 69.72 55% of Billed Charges RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC inpatient 10 ME 82.02 41.01 IMA of Louisiana Commercial PPO 69.72 percent of total billed charges 41.01 69.72 Inpatient Reimbursement at 85% of Billed Charges RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC outpatient 10 ME 82.02 65.62 IMA of Louisiana Commercial PPO 69.72 percent of total billed charges 45.11 69.72 Reimbursement at 85% of billed charges RIVAROXABAN 10MG TABLET 250 RC 5045858010 NDC outpatient 10 ME 82.02 65.62 Aetna Commercial PPO 45.11 percent of total billed charges 45.11 69.72 55 of billed Charges MORPHINE PF 1.0MG/ML 20ML SYR J8499 HCPCS 260 RC 7632919111 NDC inpatient 1 ME 51 25.5 BCBS Louisiana PPO 25.5 percent of total billed charges 25.5 43.35 50% of Eligible Charges MORPHINE PF 1.0MG/ML 20ML SYR J8499 HCPCS 260 RC 7632919111 NDC outpatient 1 ME 51 40.8 BCBS Louisiana PPO 40.8 percent of total billed charges 28.05 43.35 80% of billed charge MORPHINE PF 1.0MG/ML 20ML SYR J8499 HCPCS 260 RC 7632919111 NDC outpatient 1 ME 51 40.8 Cigna Commercial PPO 28.05 percent of total billed charges 28.05 43.35 55% of Billed Charges MORPHINE PF 1.0MG/ML 20ML SYR J8499 HCPCS 260 RC 7632919111 NDC inpatient 1 ME 51 25.5 IMA of Louisiana Commercial PPO 43.35 percent of total billed charges 25.5 43.35 Inpatient Reimbursement at 85% of Billed Charges MORPHINE PF 1.0MG/ML 20ML SYR J8499 HCPCS 260 RC 7632919111 NDC outpatient 1 ME 51 40.8 IMA of Louisiana Commercial PPO 43.35 percent of total billed charges 28.05 43.35 Reimbursement at 85% of billed charges FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC inpatient 800 UN 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC outpatient 800 UN 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC outpatient 800 UN 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC inpatient 800 UN 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC outpatient 800 UN 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges FOLIC ACID 800MCG TABLET 250 RC 5042825036 NDC outpatient 800 UN 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges BUPIVACAINE 0.75% SPINAL 2ML INJ. J3490 HCPCS 250 RC 0409176110 NDC inpatient 2 ML 11.54 5.77 BCBS Louisiana PPO 5.77 percent of total billed charges 5.77 9.81 50% of Eligible Charges BUPIVACAINE 0.75% SPINAL 2ML INJ. J3490 HCPCS 250 RC 0409176110 NDC outpatient 2 ML 11.54 9.23 BCBS Louisiana PPO 9.23 percent of total billed charges 6.35 9.81 80% of billed charge BUPIVACAINE 0.75% SPINAL 2ML INJ. J3490 HCPCS 250 RC 0409176110 NDC outpatient 2 ML 11.54 9.23 Cigna Commercial PPO 6.35 percent of total billed charges 6.35 9.81 55% of Billed Charges BUPIVACAINE 0.75% SPINAL 2ML INJ. J3490 HCPCS 250 RC 0409176110 NDC inpatient 2 ML 11.54 5.77 IMA of Louisiana Commercial PPO 9.81 percent of total billed charges 5.77 9.81 Inpatient Reimbursement at 85% of Billed Charges BUPIVACAINE 0.75% SPINAL 2ML INJ. J3490 HCPCS 250 RC 0409176110 NDC outpatient 2 ML 11.54 9.23 IMA of Louisiana Commercial PPO 9.81 percent of total billed charges 6.35 9.81 Reimbursement at 85% of billed charges MAGNESIUM 2GM/100ML NON-FORMULARY J8499 HCPCS 250 RC 6745713450 NDC inpatient 1 GR 6.9 3.45 BCBS Louisiana PPO 3.45 percent of total billed charges 3.45 5.87 50% of Eligible Charges MAGNESIUM 2GM/100ML NON-FORMULARY J8499 HCPCS 250 RC 6745713450 NDC outpatient 1 GR 6.9 5.52 BCBS Louisiana PPO 5.52 percent of total billed charges 3.8 5.87 80% of billed charge MAGNESIUM 2GM/100ML NON-FORMULARY J8499 HCPCS 250 RC 6745713450 NDC outpatient 1 GR 6.9 5.52 Cigna Commercial PPO 3.8 percent of total billed charges 3.8 5.87 55% of Billed Charges MAGNESIUM 2GM/100ML NON-FORMULARY J8499 HCPCS 250 RC 6745713450 NDC inpatient 1 GR 6.9 3.45 IMA of Louisiana Commercial PPO 5.87 percent of total billed charges 3.45 5.87 Inpatient Reimbursement at 85% of Billed Charges MAGNESIUM 2GM/100ML NON-FORMULARY J8499 HCPCS 250 RC 6745713450 NDC outpatient 1 GR 6.9 5.52 IMA of Louisiana Commercial PPO 5.87 percent of total billed charges 3.8 5.87 Reimbursement at 85% of billed charges EPOETIN 10000U/ML 1ML INJ J8499 HCPCS 250 RC 5967631001 NDC inpatient 1 ML 693.92 346.96 BCBS Louisiana PPO 346.96 percent of total billed charges 346.96 589.83 50% of Eligible Charges EPOETIN 10000U/ML 1ML INJ J8499 HCPCS 250 RC 5967631001 NDC outpatient 1 ML 693.92 555.14 BCBS Louisiana PPO 555.14 percent of total billed charges 381.66 589.83 80% of billed charge EPOETIN 10000U/ML 1ML INJ J8499 HCPCS 250 RC 5967631001 NDC outpatient 1 ML 693.92 555.14 Cigna Commercial PPO 381.66 percent of total billed charges 381.66 589.83 55% of Billed Charges EPOETIN 10000U/ML 1ML INJ J8499 HCPCS 250 RC 5967631001 NDC inpatient 1 ML 693.92 346.96 IMA of Louisiana Commercial PPO 589.83 percent of total billed charges 346.96 589.83 Inpatient Reimbursement at 85% of Billed Charges EPOETIN 10000U/ML 1ML INJ J8499 HCPCS 250 RC 5967631001 NDC outpatient 1 ML 693.92 555.14 IMA of Louisiana Commercial PPO 589.83 percent of total billed charges 381.66 589.83 Reimbursement at 85% of billed charges DULOXETINE 20MG CAP 250 RC 6068772321 NDC inpatient 20 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DULOXETINE 20MG CAP 250 RC 6068772321 NDC outpatient 20 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DULOXETINE 20MG CAP 250 RC 6068772321 NDC outpatient 20 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DULOXETINE 20MG CAP 250 RC 6068772321 NDC inpatient 20 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DULOXETINE 20MG CAP 250 RC 6068772321 NDC outpatient 20 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DULOXETINE 20MG CAP 250 RC 6068772321 NDC outpatient 20 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC inpatient 325 ME 3.67 1.84 BCBS Louisiana PPO 1.84 percent of total billed charges 1.84 3.12 50% of Eligible Charges HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC outpatient 325 ME 3.67 2.94 BCBS Louisiana PPO 2.94 percent of total billed charges 2.02 3.12 80% of billed charge HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC outpatient 325 ME 3.67 2.94 Cigna Commercial PPO 2.02 percent of total billed charges 2.02 3.12 55% of Billed Charges HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC inpatient 325 ME 3.67 1.84 IMA of Louisiana Commercial PPO 3.12 percent of total billed charges 1.84 3.12 Inpatient Reimbursement at 85% of Billed Charges HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC outpatient 325 ME 3.67 2.94 IMA of Louisiana Commercial PPO 3.12 percent of total billed charges 2.02 3.12 Reimbursement at 85% of billed charges HYDROCODONE/ACET 5/325MG TABLET 250 RC 0406012362 NDC outpatient 325 ME 3.67 2.94 Aetna Commercial PPO 2.02 percent of total billed charges 2.02 3.12 55 of billed Charges ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC inpatient 2 ME 922.94 461.47 BCBS Louisiana PPO 461.47 percent of total billed charges 461.47 784.5 50% of Eligible Charges ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC outpatient 2 ME 922.94 738.35 BCBS Louisiana PPO 738.35 percent of total billed charges 507.62 784.5 80% of billed charge ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC outpatient 2 ME 922.94 738.35 Cigna Commercial PPO 507.62 percent of total billed charges 507.62 784.5 55% of Billed Charges ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC inpatient 2 ME 922.94 461.47 IMA of Louisiana Commercial PPO 784.5 percent of total billed charges 461.47 784.5 Inpatient Reimbursement at 85% of Billed Charges ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC outpatient 2 ME 922.94 738.35 IMA of Louisiana Commercial PPO 784.5 percent of total billed charges 507.62 784.5 Reimbursement at 85% of billed charges ACTIVASE (ALTEPLASE) CATHFLO : 2MG SDV 250 RC 5024204164 NDC outpatient 2 ME 922.94 738.35 Aetna Commercial PPO 507.62 percent of total billed charges 507.62 784.5 55 of billed Charges LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC inpatient 4 ML 105 52.5 BCBS Louisiana PPO 52.5 percent of total billed charges 52.5 89.25 50% of Eligible Charges LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC outpatient 4 ML 105 84 BCBS Louisiana PPO 84 percent of total billed charges 57.75 89.25 80% of billed charge LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC outpatient 4 ML 105 84 Cigna Commercial PPO 57.75 percent of total billed charges 57.75 89.25 55% of Billed Charges LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC inpatient 4 ML 105 52.5 IMA of Louisiana Commercial PPO 89.25 percent of total billed charges 52.5 89.25 Inpatient Reimbursement at 85% of Billed Charges LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC outpatient 4 ML 105 84 IMA of Louisiana Commercial PPO 89.25 percent of total billed charges 57.75 89.25 Reimbursement at 85% of billed charges LIDOCAINE TOP 4% SOLUTION : 4ML 250 RC 7632963005 NDC outpatient 4 ML 105 84 Aetna Commercial PPO 57.75 percent of total billed charges 57.75 89.25 55 of billed Charges SODIUM CHL 0.9% 10ML SYRINGE J3490 HCPCS 250 RC 8290306547 NDC inpatient 10 ML 1.47 0.74 BCBS Louisiana PPO 0.74 percent of total billed charges 0.74 1.25 50% of Eligible Charges SODIUM CHL 0.9% 10ML SYRINGE J3490 HCPCS 250 RC 8290306547 NDC outpatient 10 ML 1.47 1.18 BCBS Louisiana PPO 1.18 percent of total billed charges 0.81 1.25 80% of billed charge SODIUM CHL 0.9% 10ML SYRINGE J3490 HCPCS 250 RC 8290306547 NDC outpatient 10 ML 1.47 1.18 Cigna Commercial PPO 0.81 percent of total billed charges 0.81 1.25 55% of Billed Charges SODIUM CHL 0.9% 10ML SYRINGE J3490 HCPCS 250 RC 8290306547 NDC inpatient 10 ML 1.47 0.74 IMA of Louisiana Commercial PPO 1.25 percent of total billed charges 0.74 1.25 Inpatient Reimbursement at 85% of Billed Charges SODIUM CHL 0.9% 10ML SYRINGE J3490 HCPCS 250 RC 8290306547 NDC outpatient 10 ML 1.47 1.18 IMA of Louisiana Commercial PPO 1.25 percent of total billed charges 0.81 1.25 Reimbursement at 85% of billed charges DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC inpatient 30 ME 1 0.5 BCBS Louisiana PPO 0.5 percent of total billed charges 0.5 0.85 50% of Eligible Charges DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC outpatient 30 ME 1 0.8 BCBS Louisiana PPO 0.8 percent of total billed charges 0.55 0.85 80% of billed charge DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC outpatient 30 ME 1 0.8 Cigna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55% of Billed Charges DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC inpatient 30 ME 1 0.5 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.5 0.85 Inpatient Reimbursement at 85% of Billed Charges DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC outpatient 30 ME 1 0.8 IMA of Louisiana Commercial PPO 0.85 percent of total billed charges 0.55 0.85 Reimbursement at 85% of billed charges DILTIAZEM HCL 30MG TAB 250 RC 0093031801 NDC outpatient 30 ME 1 0.8 Aetna Commercial PPO 0.55 percent of total billed charges 0.55 0.85 55 of billed Charges STERILE WATER INJ 10ML 250 RC 0409488710 NDC inpatient 10 ML 4.61 2.31 BCBS Louisiana PPO 2.31 percent of total billed charges 2.31 3.92 50% of Eligible Charges STERILE WATER INJ 10ML 250 RC 0409488710 NDC outpatient 10 ML 4.61 3.69 BCBS Louisiana PPO 3.69 percent of total billed charges 2.54 3.92 80% of billed charge STERILE WATER INJ 10ML 250 RC 0409488710 NDC outpatient 10 ML 4.61 3.69 Cigna Commercial PPO 2.54 percent of total billed charges 2.54 3.92 55% of Billed Charges STERILE WATER INJ 10ML 250 RC 0409488710 NDC inpatient 10 ML 4.61 2.31 IMA of Louisiana Commercial PPO 3.92 percent of total billed charges 2.31 3.92 Inpatient Reimbursement at 85% of Billed Charges STERILE WATER INJ 10ML 250 RC 0409488710 NDC outpatient 10 ML 4.61 3.69 IMA of Louisiana Commercial PPO 3.92 percent of total billed charges 2.54 3.92 Reimbursement at 85% of billed charges STERILE WATER INJ 10ML 250 RC 0409488710 NDC outpatient 10 ML 4.61 3.69 Aetna Commercial PPO 2.54 percent of total billed charges 2.54 3.92 55 of billed Charges KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC inpatient 10 ME 39.12 19.56 BCBS Louisiana PPO 19.56 percent of total billed charges 19.56 33.25 50% of Eligible Charges KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC outpatient 10 ME 39.12 31.3 BCBS Louisiana PPO 31.3 percent of total billed charges 21.52 33.25 80% of billed charge KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC outpatient 10 ME 39.12 31.3 Cigna Commercial PPO 21.52 percent of total billed charges 21.52 33.25 55% of Billed Charges KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC inpatient 10 ME 39.12 19.56 IMA of Louisiana Commercial PPO 33.25 percent of total billed charges 19.56 33.25 Inpatient Reimbursement at 85% of Billed Charges KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC outpatient 10 ME 39.12 31.3 IMA of Louisiana Commercial PPO 33.25 percent of total billed charges 21.52 33.25 Reimbursement at 85% of billed charges KETAMINE 10MG/ML 20ML VIAL 260 RC 2502168220 NDC outpatient 10 ME 39.12 31.3 Aetna Commercial PPO 21.52 percent of total billed charges 21.52 33.25 55 of billed Charges CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC inpatient 2 GR 71.61 35.81 BCBS Louisiana PPO 35.81 percent of total billed charges 35.81 60.87 50% of Eligible Charges CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC outpatient 2 GR 71.61 57.29 BCBS Louisiana PPO 57.29 percent of total billed charges 39.39 60.87 80% of billed charge CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC outpatient 2 GR 71.61 57.29 Cigna Commercial PPO 39.39 percent of total billed charges 39.39 60.87 55% of Billed Charges CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC inpatient 2 GR 71.61 35.81 IMA of Louisiana Commercial PPO 60.87 percent of total billed charges 35.81 60.87 Inpatient Reimbursement at 85% of Billed Charges CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC outpatient 2 GR 71.61 57.29 IMA of Louisiana Commercial PPO 60.87 percent of total billed charges 39.39 60.87 Reimbursement at 85% of billed charges CEFEPIME 2GM IVPB NON-FORMULARY 260 RC 0409973510 NDC outpatient 2 GR 71.61 57.29 Aetna Commercial PPO 39.39 percent of total billed charges 39.39 60.87 55 of billed Charges SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC inpatient 10 ML 49.2 24.6 BCBS Louisiana PPO 24.6 percent of total billed charges 24.6 41.82 50% of Eligible Charges SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC outpatient 10 ML 49.2 39.36 BCBS Louisiana PPO 39.36 percent of total billed charges 27.06 41.82 80% of billed charge SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC outpatient 10 ML 49.2 39.36 Cigna Commercial PPO 27.06 percent of total billed charges 27.06 41.82 55% of Billed Charges SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC inpatient 10 ML 49.2 24.6 IMA of Louisiana Commercial PPO 41.82 percent of total billed charges 24.6 41.82 Inpatient Reimbursement at 85% of Billed Charges SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC outpatient 10 ML 49.2 39.36 IMA of Louisiana Commercial PPO 41.82 percent of total billed charges 27.06 41.82 Reimbursement at 85% of billed charges SODIUM BICARB 8.4% INJ : 10ML VIAL 250 RC 5175450114 NDC outpatient 10 ML 49.2 39.36 Aetna Commercial PPO 27.06 percent of total billed charges 27.06 41.82 55 of billed Charges DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC inpatient 100 UN 9.6 4.8 BCBS Louisiana PPO 4.8 percent of total billed charges 4.8 8.16 50% of Eligible Charges DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC outpatient 100 UN 9.6 7.68 BCBS Louisiana PPO 7.68 percent of total billed charges 5.28 8.16 80% of billed charge DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC outpatient 100 UN 9.6 7.68 Cigna Commercial PPO 5.28 percent of total billed charges 5.28 8.16 55% of Billed Charges DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC inpatient 100 UN 9.6 4.8 IMA of Louisiana Commercial PPO 8.16 percent of total billed charges 4.8 8.16 Inpatient Reimbursement at 85% of Billed Charges DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC outpatient 100 UN 9.6 7.68 IMA of Louisiana Commercial PPO 8.16 percent of total billed charges 5.28 8.16 Reimbursement at 85% of billed charges DEXMEDETOMIDINE 200MCG/2ML VIAL 250 RC 7128850503 NDC outpatient 100 UN 9.6 7.68 Aetna Commercial PPO 5.28 percent of total billed charges 5.28 8.16 55 of billed Charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges TREAT SPINAL CANAL LESION 62282 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate INJECT SPINE L/S (CD) 62311 CPT 360 RC inpatient 2196.08 1098.04 BCBS Louisiana PPO 1098.04 percent of total billed charges 1098.04 1866.67 50% of Eligible Charges INJECT SPINE L/S (CD) 62311 CPT 360 RC outpatient 2196.08 1756.86 BCBS Louisiana PPO 1756.86 percent of total billed charges 1207.84 1866.67 80% of billed charge INJECT SPINE L/S (CD) 62311 CPT 360 RC outpatient 2196.08 1756.86 Cigna Commercial PPO 1207.84 percent of total billed charges 1207.84 1866.67 55% of Billed Charges INJECT SPINE L/S (CD) 62311 CPT 360 RC inpatient 2196.08 1098.04 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1098.04 1866.67 Inpatient Reimbursement at 85% of Billed Charges INJECT SPINE L/S (CD) 62311 CPT 360 RC outpatient 2196.08 1756.86 IMA of Louisiana Commercial PPO 1866.67 percent of total billed charges 1207.84 1866.67 Reimbursement at 85% of billed charges INJECT SPINE L/S (CD) 62311 CPT 360 RC outpatient 2196.08 1756.86 Aetna Commercial PPO 1207.84 percent of total billed charges 1207.84 1866.67 55 of billed Charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC inpatient 10143.15 5071.58 BCBS Louisiana PPO 5071.58 percent of total billed charges 5071.58 8621.68 50% of Eligible Charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC outpatient 10143.15 8114.52 BCBS Louisiana PPO 8114.52 percent of total billed charges 1300 8621.68 80% of billed charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC outpatient 10143.15 8114.52 Cigna Commercial PPO 5578.73 percent of total billed charges 1300 8621.68 55% of Billed Charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC inpatient 10143.15 5071.58 IMA of Louisiana Commercial PPO 8621.68 percent of total billed charges 5071.58 8621.68 Inpatient Reimbursement at 85% of Billed Charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC outpatient 10143.15 8114.52 IMA of Louisiana Commercial PPO 8621.68 percent of total billed charges 1300 8621.68 Reimbursement at 85% of billed charges IMPLANT NEUROELECTRODES 63650 CPT 360 RC outpatient 10143.15 8114.52 Aetna Commercial PPO 1300 fee schedule 1300 8621.68 Case Rate INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges INJ FORAMEN EPIDURAL C/T 64479 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges NJX ANES LMBR THRC PVRT SYMPATHETIC 64520 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC inpatient 38635.88 19317.94 BCBS Louisiana PPO 19317.94 percent of total billed charges 19317.94 32840.5 50% of Eligible Charges IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC outpatient 38635.88 30908.7 BCBS Louisiana PPO 30908.7 percent of total billed charges 1300 32840.5 80% of billed charges IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC outpatient 38635.88 30908.7 Cigna Commercial PPO 21249.73 percent of total billed charges 1300 32840.5 55% of Billed Charges IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC inpatient 38635.88 19317.94 IMA of Louisiana Commercial PPO 32840.5 percent of total billed charges 19317.94 32840.5 Inpatient Reimbursement at 85% of Billed Charges IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC outpatient 38635.88 30908.7 IMA of Louisiana Commercial PPO 32840.5 percent of total billed charges 1300 32840.5 Reimbursement at 85% of billed charges IMPLANT OR REPLACE OF DEVICE FOR INTRATH 62362 CPT 360 RC outpatient 38635.88 30908.7 Aetna Commercial PPO 1300 fee schedule 1300 32840.5 Case Rate NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges NBLOCK INJECTION INTERCOST MLT 64421 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC inpatient 13735.73 6867.87 BCBS Louisiana PPO 6867.87 percent of total billed charges 6867.87 11675.37 50% of Eligible Charges LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC outpatient 13735.73 10988.58 BCBS Louisiana PPO 10988.58 percent of total billed charges 1300 11675.37 80% of billed charges LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC outpatient 13735.73 10988.58 Cigna Commercial PPO 6800 case rate 1300 11675.37 6800 case rate LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC inpatient 13735.73 6867.87 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 6867.87 11675.37 Inpatient Reimbursement at 85% of Billed Charges LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC outpatient 13735.73 10988.58 IMA of Louisiana Commercial PPO 11675.37 percent of total billed charges 1300 11675.37 Reimbursement at 85% of billed charges LAMINECTOMY FACETECTOMY AND FORAMINOTOMY 63045 CPT 360 RC outpatient 13735.73 10988.58 Aetna Commercial PPO 1300 fee schedule 1300 11675.37 Case Rate NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC inpatient 1680.45 840.23 BCBS Louisiana PPO 840.23 percent of total billed charges 840.23 1428.38 50% of Eligible Charges NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC outpatient 1680.45 1344.36 BCBS Louisiana PPO 1344.36 percent of total billed charges 924.25 1428.38 80% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC outpatient 1680.45 1344.36 Cigna Commercial PPO 924.25 percent of total billed charges 924.25 1428.38 55% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC inpatient 1680.45 840.23 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 840.23 1428.38 Inpatient Reimbursement at 85% of Billed Charges NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC outpatient 1680.45 1344.36 IMA of Louisiana Commercial PPO 1428.38 percent of total billed charges 924.25 1428.38 Reimbursement at 85% of billed charges NJX DX OR THER PVRT FACET JT LMBR SAC 1 64493 CPT 360 RC outpatient 1680.45 1344.36 Aetna Commercial PPO 1300 fee schedule 924.25 1428.38 Case Rate NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges NJX ANES INTERCOSTAL NERVE 64420 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC inpatient 7198.45 3599.23 BCBS Louisiana PPO 3599.23 percent of total billed charges 3599.23 6118.68 50% of Eligible Charges RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC outpatient 7198.45 5758.76 BCBS Louisiana PPO 5758.76 percent of total billed charges 1300 6118.68 80% of billed charges RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC outpatient 7198.45 5758.76 Cigna Commercial PPO 3959.15 percent of total billed charges 1300 6118.68 55% of Billed Charges RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC inpatient 7198.45 3599.23 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 3599.23 6118.68 Inpatient Reimbursement at 85% of Billed Charges RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC outpatient 7198.45 5758.76 IMA of Louisiana Commercial PPO 6118.68 percent of total billed charges 1300 6118.68 Reimbursement at 85% of billed charges RMVL SPINAL NSTIM ELTRD PLATE PADDLE FLO 63662 CPT 360 RC outpatient 7198.45 5758.76 Aetna Commercial PPO 1300 fee schedule 1300 6118.68 Case Rate INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC inpatient 1358.45 679.23 BCBS Louisiana PPO 679.23 percent of total billed charges 679.23 1154.68 50% of Eligible Charges INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC outpatient 1358.45 1086.76 BCBS Louisiana PPO 1086.76 percent of total billed charges 747.15 1300 80% of billed charges INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC outpatient 1358.45 1086.76 Cigna Commercial PPO 747.15 percent of total billed charges 747.15 1300 55% of Billed Charges INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC inpatient 1358.45 679.23 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 679.23 1154.68 Inpatient Reimbursement at 85% of Billed Charges INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC outpatient 1358.45 1086.76 IMA of Louisiana Commercial PPO 1154.68 percent of total billed charges 747.15 1300 Reimbursement at 85% of billed charges INJECTION EPIDURAL OF BLOOD/CLOT PATCH 62273 CPT 360 RC outpatient 1358.45 1086.76 Aetna Commercial PPO 1300 fee schedule 747.15 1300 Case Rate NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges NERVE REPAIR WITH AUTOGENOUS VEIN GRAFT 64911 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC inpatient 11913.65 5956.83 BCBS Louisiana PPO 5956.83 percent of total billed charges 5956.83 10126.6 50% of Eligible Charges ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC outpatient 11913.65 9530.92 BCBS Louisiana PPO 9530.92 percent of total billed charges 1300 10126.6 80% of billed charges ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC outpatient 11913.65 9530.92 Cigna Commercial PPO 6552.51 percent of total billed charges 1300 10126.6 55% of Billed Charges ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC inpatient 11913.65 5956.83 IMA of Louisiana Commercial PPO 10126.6 percent of total billed charges 5956.83 10126.6 Inpatient Reimbursement at 85% of Billed Charges ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC outpatient 11913.65 9530.92 IMA of Louisiana Commercial PPO 10126.6 percent of total billed charges 1300 10126.6 Reimbursement at 85% of billed charges ARTHROSCOPY HIP W/LABRAL REPAIR 29916 CPT 360 RC outpatient 11913.65 9530.92 Aetna Commercial PPO 1300 fee schedule 1300 10126.6 Case Rate DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC inpatient 422.38 211.19 BCBS Louisiana PPO 211.19 percent of total billed charges 211.19 359.02 50% of Eligible Charges DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC outpatient 422.38 337.9 BCBS Louisiana PPO 337.9 percent of total billed charges 232.31 359.02 80% of billed charge DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC outpatient 422.38 337.9 Cigna Commercial PPO 232.31 percent of total billed charges 232.31 359.02 55% of Billed Charges DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC inpatient 422.38 211.19 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 211.19 359.02 Inpatient Reimbursement at 85% of Billed Charges DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC outpatient 422.38 337.9 IMA of Louisiana Commercial PPO 359.02 percent of total billed charges 232.31 359.02 Reimbursement at 85% of billed charges DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 CPT 360 RC outpatient 422.38 337.9 Aetna Commercial PPO 232.31 percent of total billed charges 232.31 359.02 55 of billed Charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC inpatient 3945.73 1972.87 BCBS Louisiana PPO 1972.87 percent of total billed charges 1972.87 3353.87 50% of Eligible Charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC outpatient 3945.73 3156.58 BCBS Louisiana PPO 3156.58 percent of total billed charges 1300 3353.87 80% of billed charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC outpatient 3945.73 3156.58 Cigna Commercial PPO 2170.15 percent of total billed charges 1300 3353.87 55% of Billed Charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC inpatient 3945.73 1972.87 IMA of Louisiana Commercial PPO 3353.87 percent of total billed charges 1972.87 3353.87 Inpatient Reimbursement at 85% of Billed Charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC outpatient 3945.73 3156.58 IMA of Louisiana Commercial PPO 3353.87 percent of total billed charges 1300 3353.87 Reimbursement at 85% of billed charges DST NROLYTC AGNT PARVERTEB FCT 64633 CPT 360 RC outpatient 3945.73 3156.58 Aetna Commercial PPO 1300 fee schedule 1300 3353.87 Case Rate DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC inpatient 10662.4 5331.2 BCBS Louisiana PPO 5331.2 percent of total billed charges 5331.2 9063.04 50% of Eligible Charges DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC outpatient 10662.4 8529.92 BCBS Louisiana PPO 8529.92 percent of total billed charges 100 9063.04 80% of billed charges DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC outpatient 10662.4 8529.92 Cigna Commercial PPO 5864.32 percent of total billed charges 100 9063.04 55% of Billed Charges DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC inpatient 10662.4 5331.2 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 5331.2 9063.04 Inpatient Reimbursement at 85% of Billed Charges DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC outpatient 10662.4 8529.92 IMA of Louisiana Commercial PPO 9063.04 percent of total billed charges 100 9063.04 Reimbursement at 85% of billed charges DIR RPR ARYSM&GRF INSJ RDL/UR ART 35045 CPT 360 RC outpatient 10662.4 8529.92 Aetna Commercial PPO 100 fee schedule 100 9063.04 Case Rate PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC inpatient 140 70 BCBS Louisiana PPO 70 percent of total billed charges 70 119 50% of Eligible Charges PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC outpatient 140 112 BCBS Louisiana PPO 112 percent of total billed charges 77 119 80% of billed charge PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC outpatient 140 112 Cigna Commercial PPO 85 other 77 119 63% of Billed Charges PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC inpatient 140 70 IMA of Louisiana Commercial PPO 119 percent of total billed charges 70 119 Inpatient Reimbursement at 85% of Billed Charges PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC outpatient 140 112 IMA of Louisiana Commercial PPO 119 percent of total billed charges 77 119 Reimbursement at 85% of billed charges PHYSICAL THERAPY EVALUATION NEW PATIENT 97001 CPT 424 RC outpatient 140 112 Aetna Commercial PPO 77 percent of total billed charges 77 119 55 of billed Charges PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC inpatient 57.72 28.86 BCBS Louisiana PPO 28.86 percent of total billed charges 28.86 49.06 50% of Eligible Charges PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC outpatient 57.72 46.18 BCBS Louisiana PPO 46.18 percent of total billed charges 31.75 85 80% of billed charge PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC outpatient 57.72 46.18 Cigna Commercial PPO 85 other 31.75 85 63% of Billed Charges PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC inpatient 57.72 28.86 IMA of Louisiana Commercial PPO 49.06 percent of total billed charges 28.86 49.06 Inpatient Reimbursement at 85% of Billed Charges PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC outpatient 57.72 46.18 IMA of Louisiana Commercial PPO 49.06 percent of total billed charges 31.75 85 Reimbursement at 85% of billed charges PHYSICAL THERAPY TNS EVALUATION 64550 CPT 424 RC outpatient 57.72 46.18 Aetna Commercial PPO 31.75 percent of total billed charges 31.75 85 55 of billed Charges PT MASSAGE 97124 CPT 421 RC inpatient 76.98 38.49 BCBS Louisiana PPO 38.49 percent of total billed charges 38.49 65.43 50% of Eligible Charges PT MASSAGE 97124 CPT 421 RC outpatient 76.98 61.58 BCBS Louisiana PPO 61.58 percent of total billed charges 50.06 85 80% of billed charge PT MASSAGE 97124 CPT 421 RC outpatient 76.98 61.58 Cigna Commercial PPO 85 other 50.06 85 63% of Billed Charges PT MASSAGE 97124 CPT 421 RC inpatient 76.98 38.49 IMA of Louisiana Commercial PPO 65.43 percent of total billed charges 38.49 65.43 Inpatient Reimbursement at 85% of Billed Charges PT MASSAGE 97124 CPT 421 RC outpatient 76.98 61.58 IMA of Louisiana Commercial PPO 65.43 percent of total billed charges 50.06 85 Reimbursement at 85% of billed charges PT MASSAGE 97124 CPT 421 RC outpatient 76.98 61.58 Aetna Commercial PPO 50.06 fee schedule 50.06 85 200% Of Aetna Market Fee Schedule PT UNLISTED PROCEDURE 97139 CPT 421 RC inpatient 59.82 29.91 BCBS Louisiana PPO 29.91 percent of total billed charges 29.91 50.85 50% of Eligible Charges PT UNLISTED PROCEDURE 97139 CPT 421 RC outpatient 59.82 47.86 BCBS Louisiana PPO 47.86 percent of total billed charges 32.9 85 80% of billed charge PT UNLISTED PROCEDURE 97139 CPT 421 RC outpatient 59.82 47.86 Cigna Commercial PPO 85 other 32.9 85 63% of Billed Charges PT UNLISTED PROCEDURE 97139 CPT 421 RC inpatient 59.82 29.91 IMA of Louisiana Commercial PPO 50.85 percent of total billed charges 29.91 50.85 Inpatient Reimbursement at 85% of Billed Charges PT UNLISTED PROCEDURE 97139 CPT 421 RC outpatient 59.82 47.86 IMA of Louisiana Commercial PPO 50.85 percent of total billed charges 32.9 85 Reimbursement at 85% of billed charges PT UNLISTED PROCEDURE 97139 CPT 421 RC outpatient 59.82 47.86 Aetna Commercial PPO 32.9 percent of total billed charges 32.9 85 55 of billed Charges AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC inpatient 98.53 49.27 BCBS Louisiana PPO 49.27 percent of total billed charges 49.27 83.75 50% of Eligible Charges AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC outpatient 98.53 78.82 BCBS Louisiana PPO 78.82 percent of total billed charges 78.82 85 80% of billed charge AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC outpatient 98.53 78.82 Cigna Commercial PPO 85 other 78.82 85 63% of Billed Charges AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC inpatient 98.53 49.27 IMA of Louisiana Commercial PPO 83.75 percent of total billed charges 49.27 83.75 Inpatient Reimbursement at 85% of Billed Charges AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC outpatient 98.53 78.82 IMA of Louisiana Commercial PPO 83.75 percent of total billed charges 78.82 85 Reimbursement at 85% of billed charges AQUATIC THERAPEUTIC EXERCISES 97113 CPT 421 RC outpatient 98.53 78.82 Aetna Commercial PPO 80.64 fee schedule 78.82 85 200% Of Aetna Market Fee Schedule LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC E 63044 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC inpatient 6231.85 3115.93 BCBS Louisiana PPO 3115.93 percent of total billed charges 3115.93 5297.07 50% of Eligible Charges REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC outpatient 6231.85 4985.48 BCBS Louisiana PPO 4985.48 percent of total billed charges 1300 5297.07 80% of billed charges REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC outpatient 6231.85 4985.48 Cigna Commercial PPO 3427.52 percent of total billed charges 1300 5297.07 55% of Billed Charges REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC inpatient 6231.85 3115.93 IMA of Louisiana Commercial PPO 5297.07 percent of total billed charges 3115.93 5297.07 Inpatient Reimbursement at 85% of Billed Charges REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC outpatient 6231.85 4985.48 IMA of Louisiana Commercial PPO 5297.07 percent of total billed charges 1300 5297.07 Reimbursement at 85% of billed charges REPAIR BLOOD VESSEL DIRECT UPPER EXTREMI 35206 CPT 360 RC outpatient 6231.85 4985.48 Aetna Commercial PPO 1300 fee schedule 1300 5297.07 Case Rate ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC inpatient 21511.2 10755.6 BCBS Louisiana PPO 10755.6 percent of total billed charges 10755.6 18284.52 50% of Eligible Charges ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC outpatient 21511.2 17208.96 BCBS Louisiana PPO 17208.96 percent of total billed charges 1300 18284.52 80% of billed charges ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC outpatient 21511.2 17208.96 Cigna Commercial PPO 11831.16 percent of total billed charges 1300 18284.52 55% of Billed Charges ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC inpatient 21511.2 10755.6 IMA of Louisiana Commercial PPO 18284.52 percent of total billed charges 10755.6 18284.52 Inpatient Reimbursement at 85% of Billed Charges ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC outpatient 21511.2 17208.96 IMA of Louisiana Commercial PPO 18284.52 percent of total billed charges 1300 18284.52 Reimbursement at 85% of billed charges ARTHRITIS AID TIBIAL FX PROX UNI-BI COND 29856 CPT 360 RC outpatient 21511.2 17208.96 Aetna Commercial PPO 1300 fee schedule 1300 18284.52 Case Rate VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 100 11913.64 80% of billed charges VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 7708.83 percent of total billed charges 100 11913.64 55% of Billed Charges VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 100 11913.64 Reimbursement at 85% of billed charges VCRPEC TRANSPLANT/RPR DCMPRN THRC LMBR 63090 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 100 fee schedule 100 11913.64 Case Rate REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC inpatient 4026.25 2013.13 BCBS Louisiana PPO 2013.13 percent of total billed charges 2013.13 3422.31 50% of Eligible Charges REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC outpatient 4026.25 3221 BCBS Louisiana PPO 3221 percent of total billed charges 1300 3422.31 80% of billed charges REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC outpatient 4026.25 3221 Cigna Commercial PPO 2214.44 percent of total billed charges 1300 3422.31 55% of Billed Charges REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC inpatient 4026.25 2013.13 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 2013.13 3422.31 Inpatient Reimbursement at 85% of Billed Charges REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC outpatient 4026.25 3221 IMA of Louisiana Commercial PPO 3422.31 percent of total billed charges 1300 3422.31 Reimbursement at 85% of billed charges REMOVE SPINAL CANAL CATHETER 62355 CPT 360 RC outpatient 4026.25 3221 Aetna Commercial PPO 1300 fee schedule 1300 3422.31 Case Rate NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC inpatient 11568.98 5784.49 BCBS Louisiana PPO 5784.49 percent of total billed charges 5784.49 9833.63 50% of Eligible Charges NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC outpatient 11568.98 9255.18 BCBS Louisiana PPO 9255.18 percent of total billed charges 1300 9833.63 80% of billed charges NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC outpatient 11568.98 9255.18 Cigna Commercial PPO 6362.94 percent of total billed charges 1300 9833.63 55% of Billed Charges NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC inpatient 11568.98 5784.49 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 5784.49 9833.63 Inpatient Reimbursement at 85% of Billed Charges NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC outpatient 11568.98 9255.18 IMA of Louisiana Commercial PPO 9833.63 percent of total billed charges 1300 9833.63 Reimbursement at 85% of billed charges NERVE GRAFT HAND/FOOT >4 CM 64896 CPT 360 RC outpatient 11568.98 9255.18 Aetna Commercial PPO 1300 fee schedule 1300 9833.63 Case Rate US XTR NON-VASC COMPLETE 76881 CPT 360 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges US XTR NON-VASC COMPLETE 76881 CPT 360 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges US XTR NON-VASC COMPLETE 76881 CPT 360 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges US XTR NON-VASC COMPLETE 76881 CPT 360 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges US XTR NON-VASC COMPLETE 76881 CPT 360 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges US XTR NON-VASC COMPLETE 76881 CPT 360 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC inpatient 611.75 305.88 BCBS Louisiana PPO 305.88 percent of total billed charges 305.88 519.99 50% of Eligible Charges N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC outpatient 611.75 489.4 BCBS Louisiana PPO 489.4 percent of total billed charges 336.46 1300 80% of billed charges N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC outpatient 611.75 489.4 Cigna Commercial PPO 336.46 percent of total billed charges 336.46 1300 55% of Billed Charges N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC inpatient 611.75 305.88 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 305.88 519.99 Inpatient Reimbursement at 85% of Billed Charges N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC outpatient 611.75 489.4 IMA of Louisiana Commercial PPO 519.99 percent of total billed charges 336.46 1300 Reimbursement at 85% of billed charges N BLOCK INJ TRIGEMINAL 64400 CPT 360 RC outpatient 611.75 489.4 Aetna Commercial PPO 1300 fee schedule 336.46 1300 Case Rate Excise Intrspinl Lesion Thrc 63266 CPT 360 RC inpatient 14016.05 7008.03 BCBS Louisiana PPO 7008.03 percent of total billed charges 7008.03 11913.64 50% of Eligible Charges Excise Intrspinl Lesion Thrc 63266 CPT 360 RC outpatient 14016.05 11212.84 BCBS Louisiana PPO 11212.84 percent of total billed charges 1300 11913.64 80% of billed charges Excise Intrspinl Lesion Thrc 63266 CPT 360 RC outpatient 14016.05 11212.84 Cigna Commercial PPO 6800 case rate 1300 11913.64 6800 case rate Excise Intrspinl Lesion Thrc 63266 CPT 360 RC inpatient 14016.05 7008.03 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 7008.03 11913.64 Inpatient Reimbursement at 85% of Billed Charges Excise Intrspinl Lesion Thrc 63266 CPT 360 RC outpatient 14016.05 11212.84 IMA of Louisiana Commercial PPO 11913.64 percent of total billed charges 1300 11913.64 Reimbursement at 85% of billed charges Excise Intrspinl Lesion Thrc 63266 CPT 360 RC outpatient 14016.05 11212.84 Aetna Commercial PPO 1300 fee schedule 1300 11913.64 Case Rate XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX ACROMIOCLAVICULAR 73050 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC inpatient 155.3 77.65 BCBS Louisiana PPO 77.65 percent of total billed charges 77.65 132.01 50% of Eligible Charges XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 BCBS Louisiana PPO 108.71 percent of total billed charges 85.42 700 70% of billed charges XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 Cigna Commercial PPO 85.42 percent of total billed charges 85.42 700 55% of Billed Charges XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC inpatient 155.3 77.65 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 77.65 132.01 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 IMA of Louisiana Commercial PPO 132.01 percent of total billed charges 85.42 700 Reimbursement at 85% of billed charges XRAY DX RT CALCANEUS(HEEL) 73650 CPT 320 RC outpatient 155.3 108.71 Aetna Commercial PPO 700 case rate 85.42 700 700 Per Code Per DOS Paid In Addition XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC inpatient 220 110 BCBS Louisiana PPO 110 percent of total billed charges 110 187 50% of Eligible Charges XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 BCBS Louisiana PPO 176 percent of total billed charges 121 187 80% of billed charge XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 Cigna Commercial PPO 121 percent of total billed charges 121 187 55% of Billed Charges XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC inpatient 220 110 IMA of Louisiana Commercial PPO 187 percent of total billed charges 110 187 Inpatient Reimbursement at 85% of Billed Charges XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 IMA of Louisiana Commercial PPO 187 percent of total billed charges 121 187 Reimbursement at 85% of billed charges XRAY DX RT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 Aetna Commercial PPO 121 percent of total billed charges 121 187 55 of billed Charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY DX LT HAND 2 VIEWS 73120 CPT 320 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC inpatient 220 110 BCBS Louisiana PPO 110 percent of total billed charges 110 187 50% of Eligible Charges XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 BCBS Louisiana PPO 176 percent of total billed charges 121 187 80% of billed charge XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 Cigna Commercial PPO 121 percent of total billed charges 121 187 55% of Billed Charges XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC inpatient 220 110 IMA of Louisiana Commercial PPO 187 percent of total billed charges 110 187 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 IMA of Louisiana Commercial PPO 187 percent of total billed charges 121 187 Reimbursement at 85% of billed charges XRAY DX LT HIP BILATERAL W 73520 CPT 320 RC outpatient 220 176 Aetna Commercial PPO 121 percent of total billed charges 121 187 55 of billed Charges XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC inpatient 235 117.5 BCBS Louisiana PPO 117.5 percent of total billed charges 117.5 199.75 50% of Eligible Charges XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 BCBS Louisiana PPO 188 percent of total billed charges 129.25 199.75 80% of billed charge XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 Cigna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55% of Billed Charges XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC inpatient 235 117.5 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 117.5 199.75 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 IMA of Louisiana Commercial PPO 199.75 percent of total billed charges 129.25 199.75 Reimbursement at 85% of billed charges XRAY DX LT HIP OPRTVE UPTO 73530 CPT 320 RC outpatient 235 188 Aetna Commercial PPO 129.25 percent of total billed charges 129.25 199.75 55 of billed Charges XRAY DX LT SCAPULA 73010 CPT 320 RC inpatient 90.45 45.23 BCBS Louisiana PPO 45.23 percent of total billed charges 45.23 76.88 50% of Eligible Charges XRAY DX LT SCAPULA 73010 CPT 320 RC outpatient 90.45 63.32 BCBS Louisiana PPO 63.32 percent of total billed charges 49.75 700 70% of billed charges XRAY DX LT SCAPULA 73010 CPT 320 RC outpatient 90.45 63.32 Cigna Commercial PPO 49.75 percent of total billed charges 49.75 700 55% of Billed Charges XRAY DX LT SCAPULA 73010 CPT 320 RC inpatient 90.45 45.23 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 45.23 76.88 Inpatient Reimbursement at 85% of Billed Charges XRAY DX LT SCAPULA 73010 CPT 320 RC outpatient 90.45 63.32 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 49.75 700 Reimbursement at 85% of billed charges XRAY DX LT SCAPULA 73010 CPT 320 RC outpatient 90.45 63.32 Aetna Commercial PPO 700 case rate 49.75 700 700 Per Code Per DOS Paid In Addition C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges C-ARM 10.01-15 MINUTES PAIN INJECTION 77003 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition C-ARM PAIN INJ. 5-10 77003 CPT 320 RC inpatient 1.63 0.82 BCBS Louisiana PPO 0.82 percent of total billed charges 0.82 1.39 50% of Eligible Charges C-ARM PAIN INJ. 5-10 77003 CPT 320 RC outpatient 1.63 1.14 BCBS Louisiana PPO 1.14 percent of total billed charges 0.9 700 70% of billed charges C-ARM PAIN INJ. 5-10 77003 CPT 320 RC outpatient 1.63 1.14 Cigna Commercial PPO 0.9 percent of total billed charges 0.9 700 55% of Billed Charges C-ARM PAIN INJ. 5-10 77003 CPT 320 RC inpatient 1.63 0.82 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.82 1.39 Inpatient Reimbursement at 85% of Billed Charges C-ARM PAIN INJ. 5-10 77003 CPT 320 RC outpatient 1.63 1.14 IMA of Louisiana Commercial PPO 1.39 percent of total billed charges 0.9 700 Reimbursement at 85% of billed charges C-ARM PAIN INJ. 5-10 77003 CPT 320 RC outpatient 1.63 1.14 Aetna Commercial PPO 700 case rate 0.9 700 700 Per Code Per DOS Paid In Addition XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges XRAY ABDOMEN COMP. ACUTE ABD SER. - PRO 74022 CPT 972 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC inpatient 90.45 45.23 BCBS Louisiana PPO 45.23 percent of total billed charges 45.23 76.88 50% of Eligible Charges XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC outpatient 90.45 63.32 BCBS Louisiana PPO 63.32 percent of total billed charges 49.75 700 70% of billed charges XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC outpatient 90.45 63.32 Cigna Commercial PPO 49.75 percent of total billed charges 49.75 700 55% of Billed Charges XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC inpatient 90.45 45.23 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 45.23 76.88 Inpatient Reimbursement at 85% of Billed Charges XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC outpatient 90.45 63.32 IMA of Louisiana Commercial PPO 76.88 percent of total billed charges 49.75 700 Reimbursement at 85% of billed charges XRAY DX WRIST LT 3 VIEW 73110 CPT 320 RC outpatient 90.45 63.32 Aetna Commercial PPO 700 case rate 49.75 700 700 Per Code Per DOS Paid In Addition ULTRASOUND FETAL MONITORING 76815 CPT 402 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges ULTRASOUND FETAL MONITORING 76815 CPT 402 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 157.38 700 70% of billed charges ULTRASOUND FETAL MONITORING 76815 CPT 402 RC outpatient 286.15 200.31 Cigna Commercial PPO 157.38 percent of total billed charges 157.38 700 55% of Billed Charges ULTRASOUND FETAL MONITORING 76815 CPT 402 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges ULTRASOUND FETAL MONITORING 76815 CPT 402 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 157.38 700 Reimbursement at 85% of billed charges ULTRASOUND FETAL MONITORING 76815 CPT 402 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 157.38 700 700 Per Code Per DOS Paid In Addition PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC inpatient 202.74 101.37 BCBS Louisiana PPO 101.37 percent of total billed charges 101.37 172.33 50% of Eligible Charges PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC outpatient 202.74 162.19 BCBS Louisiana PPO 162.19 percent of total billed charges 85 172.33 80% of billed charge PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC outpatient 202.74 162.19 Cigna Commercial PPO 85 other 85 172.33 63% of Billed Charges PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC inpatient 202.74 101.37 IMA of Louisiana Commercial PPO 172.33 percent of total billed charges 101.37 172.33 Inpatient Reimbursement at 85% of Billed Charges PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC outpatient 202.74 162.19 IMA of Louisiana Commercial PPO 172.33 percent of total billed charges 85 172.33 Reimbursement at 85% of billed charges PT PHYSICAL PERFORMANCE TEST OR MEASUREM 97750 CPT 421 RC outpatient 202.74 162.19 Aetna Commercial PPO 111.51 percent of total billed charges 85 172.33 55 of billed Charges PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC inpatient 31.57 15.79 BCBS Louisiana PPO 15.79 percent of total billed charges 15.79 26.83 50% of Eligible Charges PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC outpatient 31.57 25.26 BCBS Louisiana PPO 25.26 percent of total billed charges 25.26 85 80% of billed charge PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC outpatient 31.57 25.26 Cigna Commercial PPO 85 other 25.26 85 63% of Billed Charges PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC inpatient 31.57 15.79 IMA of Louisiana Commercial PPO 26.83 percent of total billed charges 15.79 26.83 Inpatient Reimbursement at 85% of Billed Charges PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC outpatient 31.57 25.26 IMA of Louisiana Commercial PPO 26.83 percent of total billed charges 25.26 85 Reimbursement at 85% of billed charges PT SELF-CARE/HOME MANAGEMENT TRAINING 97535 CPT 421 RC outpatient 31.57 25.26 Aetna Commercial PPO 66.98 fee schedule 25.26 85 200% Of Aetna Market Fee Schedule CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC inpatient 286.15 143.08 BCBS Louisiana PPO 143.08 percent of total billed charges 143.08 243.23 50% of Eligible Charges CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 BCBS Louisiana PPO 200.31 percent of total billed charges 200.31 700 70% of billed charges CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 Cigna Commercial PPO 700 other 200.31 700 $700 Per Visit CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC inpatient 286.15 143.08 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 143.08 243.23 Inpatient Reimbursement at 85% of Billed Charges CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 IMA of Louisiana Commercial PPO 243.23 percent of total billed charges 200.31 700 Reimbursement at 85% of billed charges CT LEFT LOWER EXTREMITY W/O CONTRAST 73700 CPT 352 RC outpatient 286.15 200.31 Aetna Commercial PPO 700 case rate 200.31 700 700 Per Code Per DOS Paid In Addition CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC inpatient 631.85 315.93 BCBS Louisiana PPO 315.93 percent of total billed charges 315.93 537.07 50% of Eligible Charges CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC outpatient 631.85 442.3 BCBS Louisiana PPO 442.3 percent of total billed charges 442.3 700 70% of billed charges CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC outpatient 631.85 442.3 Cigna Commercial PPO 700 other 442.3 700 $700 Per Visit CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC inpatient 631.85 315.93 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 315.93 537.07 Inpatient Reimbursement at 85% of Billed Charges CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC outpatient 631.85 442.3 IMA of Louisiana Commercial PPO 537.07 percent of total billed charges 442.3 700 Reimbursement at 85% of billed charges CT LEFT UPPER EXTREMITY W/O CONTRAST 73201 CPT 352 RC outpatient 631.85 442.3 Aetna Commercial PPO 700 case rate 442.3 700 700 Per Code Per DOS Paid In Addition PT SQUARE CENTIMETERS 97598 CPT 421 RC inpatient 272.76 136.38 BCBS Louisiana PPO 136.38 percent of total billed charges 136.38 231.85 50% of Eligible Charges PT SQUARE CENTIMETERS 97598 CPT 421 RC outpatient 272.76 218.21 BCBS Louisiana PPO 218.21 percent of total billed charges 85 231.85 80% of billed charge PT SQUARE CENTIMETERS 97598 CPT 421 RC outpatient 272.76 218.21 Cigna Commercial PPO 85 other 85 231.85 63% of Billed Charges PT SQUARE CENTIMETERS 97598 CPT 421 RC inpatient 272.76 136.38 IMA of Louisiana Commercial PPO 231.85 percent of total billed charges 136.38 231.85 Inpatient Reimbursement at 85% of Billed Charges PT SQUARE CENTIMETERS 97598 CPT 421 RC outpatient 272.76 218.21 IMA of Louisiana Commercial PPO 231.85 percent of total billed charges 85 231.85 Reimbursement at 85% of billed charges PT SQUARE CENTIMETERS 97598 CPT 421 RC outpatient 272.76 218.21 Aetna Commercial PPO 150.02 percent of total billed charges 85 231.85 55 of billed Charges PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC inpatient 29.86 14.93 BCBS Louisiana PPO 14.93 percent of total billed charges 14.93 25.38 50% of Eligible Charges PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC outpatient 29.86 23.89 BCBS Louisiana PPO 23.89 percent of total billed charges 23.89 85 80% of billed charge PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC outpatient 29.86 23.89 Cigna Commercial PPO 85 other 23.89 85 63% of Billed Charges PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC inpatient 29.86 14.93 IMA of Louisiana Commercial PPO 25.38 percent of total billed charges 14.93 25.38 Inpatient Reimbursement at 85% of Billed Charges PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC outpatient 29.86 23.89 IMA of Louisiana Commercial PPO 25.38 percent of total billed charges 23.89 85 Reimbursement at 85% of billed charges PT THERAPEAUTIC ACTIVITY 97110 CPT 424 RC outpatient 29.86 23.89 Aetna Commercial PPO 61.9 fee schedule 23.89 85 200% Of Aetna Market Fee Schedule SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 DRG ",,," inpatient 27108.57 BCBS Louisiana PPO 27108.57 fee schedule 22175.4 27189.27 "Base Rate $7,946" SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 DRG ",,," inpatient 27108.57 Cigna Commercial PPO 22175.4 fee schedule 22175.4 27189.27 Base rate of $6500 SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 DRG ",,," inpatient 27108.57 Aetna Commercial PPO 27189.27 fee schedule 22175.4 27189.27 100% of DRG fee schedule SPINAL PROCEDURES WITHOUT CC/MCC 030 DRG ",,," inpatient 17443.06 BCBS Louisiana PPO 17443.06 fee schedule 14268.8 18025.74 "Base Rate $7,946" SPINAL PROCEDURES WITHOUT CC/MCC 030 DRG ",,," inpatient 17443.06 Cigna Commercial PPO 14268.8 fee schedule 14268.8 18025.74 Base rate of $6500 SPINAL PROCEDURES WITHOUT CC/MCC 030 DRG ",,," inpatient 17443.06 Aetna Commercial PPO 18025.74 fee schedule 14268.8 18025.74 100% of DRG fee schedule "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC" 040 DRG ",,," inpatient 30681.1 BCBS Louisiana PPO 30681.1 fee schedule 25097.8 30681.1 "Base Rate $7,946" "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC" 040 DRG ",,," inpatient 30681.1 Cigna Commercial PPO 25097.8 fee schedule 25097.8 30681.1 Base rate of $6500 "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC" 040 DRG ",,," inpatient 30681.1 Aetna Commercial PPO 30554.01 fee schedule 25097.8 30681.1 100% of DRG fee schedule "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC" 042 DRG ",,," inpatient 13728.3 BCBS Louisiana PPO 13728.3 fee schedule 11230.05 14236.56 "Base Rate $7,946" "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC" 042 DRG ",,," inpatient 13728.3 Cigna Commercial PPO 11230.05 fee schedule 11230.05 14236.56 Base rate of $6500 "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC" 042 DRG ",,," inpatient 13728.3 Aetna Commercial PPO 14236.56 fee schedule 11230.05 14236.56 100% of DRG fee schedule OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 DRG ",,," inpatient 6327.4 BCBS Louisiana PPO 6327.4 fee schedule 5175.95 6393.33 "Base Rate $7,946" OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 DRG ",,," inpatient 6327.4 Cigna Commercial PPO 5175.95 fee schedule 5175.95 6393.33 Base rate of $6500 OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 DRG ",,," inpatient 6327.4 Aetna Commercial PPO 6393.33 fee schedule 5175.95 6393.33 100% of DRG fee schedule SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL 402 DRG ",,," inpatient 31946.89 BCBS Louisiana PPO 31946.89 fee schedule 26133.25 31946.89 "Base Rate $7,946" SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL 402 DRG ",,," inpatient 31946.89 Cigna Commercial PPO 26133.25 fee schedule 26133.25 31946.89 Base rate of $6500 SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL 402 DRG ",,," inpatient 31946.89 Aetna Commercial PPO 31688.82 fee schedule 26133.25 31946.89 100% of DRG fee schedule MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE 426 DRG ",,," inpatient 87574.46 BCBS Louisiana PPO 87574.46 fee schedule 71637.8 87574.46 "Base Rate $7,946" MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE 426 DRG ",,," inpatient 87574.46 Cigna Commercial PPO 71637.8 fee schedule 71637.8 87574.46 Base rate of $6500 MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE 426 DRG ",,," inpatient 87574.46 Aetna Commercial PPO 84850.74 fee schedule 71637.8 87574.46 100% of DRG fee schedule MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC 427 DRG ",,," inpatient 57359 BCBS Louisiana PPO 57359 fee schedule 46920.9 57531.87 "Base Rate $7,946" MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC 427 DRG ",,," inpatient 57359 Cigna Commercial PPO 46920.9 fee schedule 46920.9 57531.87 Base rate of $6500 MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC 427 DRG ",,," inpatient 57359 Aetna Commercial PPO 57531.87 fee schedule 46920.9 57531.87 100% of DRG fee schedule MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC 428 DRG ",,," inpatient 44672.41 BCBS Louisiana PPO 44672.41 fee schedule 36543 44672.41 "Base Rate $7,946" MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC 428 DRG ",,," inpatient 44672.41 Cigna Commercial PPO 36543 fee schedule 36543 44672.41 Base rate of $6500 MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC 428 DRG ",,," inpatient 44672.41 Aetna Commercial PPO 44583.21 fee schedule 36543 44672.41 100% of DRG fee schedule COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC 429 DRG ",,," inpatient 71590.28 BCBS Louisiana PPO 71590.28 fee schedule 58562.4 71590.28 "Base Rate $7,946" COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC 429 DRG ",,," inpatient 71590.28 Cigna Commercial PPO 58562.4 fee schedule 58562.4 71590.28 Base rate of $6500 COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC 429 DRG ",,," inpatient 71590.28 Aetna Commercial PPO 67558.86 fee schedule 58562.4 71590.28 100% of DRG fee schedule COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC 430 DRG ",,," inpatient 45825.38 BCBS Louisiana PPO 45825.38 fee schedule 37486.15 45825.38 "Base Rate $7,946" COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC 430 DRG ",,," inpatient 45825.38 Cigna Commercial PPO 37486.15 fee schedule 37486.15 45825.38 Base rate of $6500 COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC 430 DRG ",,," inpatient 45825.38 Aetna Commercial PPO 44311.05 fee schedule 37486.15 45825.38 100% of DRG fee schedule MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 448 DRG ",,," inpatient 33697.4 BCBS Louisiana PPO 33697.4 fee schedule 27565.2 33697.4 "Base Rate $7,946" MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 448 DRG ",,," inpatient 33697.4 Cigna Commercial PPO 27565.2 fee schedule 27565.2 33697.4 Base rate of $6500 MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 448 DRG ",,," inpatient 33697.4 Aetna Commercial PPO 33076.35 fee schedule 27565.2 33697.4 100% of DRG fee schedule SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 451 DRG ",,," inpatient 25668.76 BCBS Louisiana PPO 25668.76 fee schedule 20997.6 25668.76 "Base Rate $7,946" SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 451 DRG ",,," inpatient 25668.76 Cigna Commercial PPO 20997.6 fee schedule 20997.6 25668.76 Base rate of $6500 SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 451 DRG ",,," inpatient 25668.76 Aetna Commercial PPO 24996.6 fee schedule 20997.6 25668.76 100% of DRG fee schedule "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC" 457 DRG ",,," inpatient 47382.79 BCBS Louisiana PPO 47382.79 fee schedule 38760.15 47382.79 "Base Rate $7,946" "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC" 457 DRG ",,," inpatient 47382.79 Cigna Commercial PPO 38760.15 fee schedule 38760.15 47382.79 Base rate of $6500 "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC" 457 DRG ",,," inpatient 47382.79 Aetna Commercial PPO 46489.14 fee schedule 38760.15 47382.79 100% of DRG fee schedule "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC" 458 DRG ",,," inpatient 33155.48 BCBS Louisiana PPO 33155.48 fee schedule 27121.9 34975.8 "Base Rate $7,946" "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC" 458 DRG ",,," inpatient 33155.48 Cigna Commercial PPO 27121.9 fee schedule 27121.9 34975.8 Base rate of $6500 "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC" 458 DRG ",,," inpatient 33155.48 Aetna Commercial PPO 34975.8 fee schedule 27121.9 34975.8 100% of DRG fee schedule BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC 462 DRG ",,," inpatient 21136.36 BCBS Louisiana PPO 21136.36 fee schedule 17290 23196.78 "Base Rate $7,946" BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC 462 DRG ",,," inpatient 21136.36 Cigna Commercial PPO 17290 fee schedule 17290 23196.78 Base rate of $6500 BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC 462 DRG ",,," inpatient 21136.36 Aetna Commercial PPO 23196.78 fee schedule 17290 23196.78 100% of DRG fee schedule WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 DRG ",,," inpatient 24749.41 BCBS Louisiana PPO 24749.41 fee schedule 20245.55 24749.41 "Base Rate $7,946" WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 DRG ",,," inpatient 24749.41 Cigna Commercial PPO 20245.55 fee schedule 20245.55 24749.41 Base rate of $6500 WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 DRG ",,," inpatient 24749.41 Aetna Commercial PPO 23883.66 fee schedule 20245.55 24749.41 100% of DRG fee schedule WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC 465 DRG ",,," inpatient 14491.12 BCBS Louisiana PPO 14491.12 fee schedule 11854.05 14491.12 "Base Rate $7,946" WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC 465 DRG ",,," inpatient 14491.12 Cigna Commercial PPO 11854.05 fee schedule 11854.05 14491.12 Base rate of $6500 WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC 465 DRG ",,," inpatient 14491.12 Aetna Commercial PPO 14062.41 fee schedule 11854.05 14491.12 100% of DRG fee schedule REVISION OF HIP OR KNEE REPLACEMENT WITH CC 467 DRG ",,," inpatient 28022.36 BCBS Louisiana PPO 28022.36 fee schedule 22922.9 28022.36 "Base Rate $7,946" REVISION OF HIP OR KNEE REPLACEMENT WITH CC 467 DRG ",,," inpatient 28022.36 Cigna Commercial PPO 22922.9 fee schedule 22922.9 28022.36 Base rate of $6500 REVISION OF HIP OR KNEE REPLACEMENT WITH CC 467 DRG ",,," inpatient 28022.36 Aetna Commercial PPO 27744.12 fee schedule 22922.9 28022.36 100% of DRG fee schedule REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC 468 DRG ",,," inpatient 21835.61 BCBS Louisiana PPO 21835.61 fee schedule 17862 21835.61 "Base Rate $7,946" REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC 468 DRG ",,," inpatient 21835.61 Cigna Commercial PPO 17862 fee schedule 17862 21835.61 Base rate of $6500 REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC 468 DRG ",,," inpatient 21835.61 Aetna Commercial PPO 21248.73 fee schedule 17862 21835.61 100% of DRG fee schedule MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT 469 DRG ",,," inpatient 24101.81 BCBS Louisiana PPO 24101.81 fee schedule 19715.8 26476.47 "Base Rate $7,946" MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT 469 DRG ",,," inpatient 24101.81 Cigna Commercial PPO 19715.8 fee schedule 19715.8 26476.47 Base rate of $6500 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT 469 DRG ",,," inpatient 24101.81 Aetna Commercial PPO 26476.47 fee schedule 19715.8 26476.47 100% of DRG fee schedule MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 DRG ",,," inpatient 15327.04 BCBS Louisiana PPO 15327.04 fee schedule 12537.85 15327.04 "Base Rate $7,946" MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 DRG ",,," inpatient 15327.04 Cigna Commercial PPO 12537.85 fee schedule 12537.85 15327.04 Base rate of $6500 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 DRG ",,," inpatient 15327.04 Aetna Commercial PPO 15272.55 fee schedule 12537.85 15327.04 100% of DRG fee schedule CERVICAL SPINAL FUSION WITH CC 472 DRG ",,," inpatient 23409.71 BCBS Louisiana PPO 23409.71 fee schedule 19149.65 23467.32 "Base Rate $7,946" CERVICAL SPINAL FUSION WITH CC 472 DRG ",,," inpatient 23409.71 Cigna Commercial PPO 19149.65 fee schedule 19149.65 23467.32 Base rate of $6500 CERVICAL SPINAL FUSION WITH CC 472 DRG ",,," inpatient 23409.71 Aetna Commercial PPO 23467.32 fee schedule 19149.65 23467.32 100% of DRG fee schedule CERVICAL SPINAL FUSION WITHOUT CC/MCC 473 DRG ",,," inpatient 19398.57 BCBS Louisiana PPO 19398.57 fee schedule 15868.45 19398.57 "Base Rate $7,946" CERVICAL SPINAL FUSION WITHOUT CC/MCC 473 DRG ",,," inpatient 19398.57 Cigna Commercial PPO 15868.45 fee schedule 15868.45 19398.57 Base rate of $6500 CERVICAL SPINAL FUSION WITHOUT CC/MCC 473 DRG ",,," inpatient 19398.57 Aetna Commercial PPO 19175.94 fee schedule 15868.45 19398.57 100% of DRG fee schedule BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 479 DRG ",,," inpatient 14770.82 BCBS Louisiana PPO 14770.82 fee schedule 12082.85 14770.82 "Base Rate $7,946" BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 479 DRG ",,," inpatient 14770.82 Cigna Commercial PPO 12082.85 fee schedule 12082.85 14770.82 Base rate of $6500 BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC 479 DRG ",,," inpatient 14770.82 Aetna Commercial PPO 14383.98 fee schedule 12082.85 14770.82 100% of DRG fee schedule HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 DRG ",,," inpatient 16642.9 BCBS Louisiana PPO 16642.9 fee schedule 13614.25 16806.69 "Base Rate $7,946" HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 DRG ",,," inpatient 16642.9 Cigna Commercial PPO 13614.25 fee schedule 13614.25 16806.69 Base rate of $6500 HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 DRG ",,," inpatient 16642.9 Aetna Commercial PPO 16806.69 fee schedule 13614.25 16806.69 100% of DRG fee schedule HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 DRG ",,," inpatient 12959.93 BCBS Louisiana PPO 12959.93 fee schedule 10601.5 12959.93 "Base Rate $7,946" HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 DRG ",,," inpatient 12959.93 Cigna Commercial PPO 10601.5 fee schedule 10601.5 12959.93 Base rate of $6500 HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 DRG ",,," inpatient 12959.93 Aetna Commercial PPO 12849.84 fee schedule 10601.5 12959.93 100% of DRG fee schedule MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 DRG ",,," inpatient 22025.52 BCBS Louisiana PPO 22025.52 fee schedule 18017.35 22025.52 "Base Rate $7,946" MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 DRG ",,," inpatient 22025.52 Cigna Commercial PPO 18017.35 fee schedule 18017.35 22025.52 Base rate of $6500 MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 DRG ",,," inpatient 22025.52 Aetna Commercial PPO 20640.42 fee schedule 18017.35 22025.52 100% of DRG fee schedule KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 487 DRG ",,," inpatient 12445.03 BCBS Louisiana PPO 12445.03 fee schedule 10180.3 12799.62 "Base Rate $7,946" KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 487 DRG ",,," inpatient 12445.03 Cigna Commercial PPO 10180.3 fee schedule 10180.3 12799.62 Base rate of $6500 KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 487 DRG ",,," inpatient 12445.03 Aetna Commercial PPO 12799.62 fee schedule 10180.3 12799.62 100% of DRG fee schedule KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 DRG ",,," inpatient 8874.09 BCBS Louisiana PPO 8874.09 fee schedule 7259.2 10031.04 "Base Rate $7,946" KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 DRG ",,," inpatient 8874.09 Cigna Commercial PPO 7259.2 fee schedule 7259.2 10031.04 Base rate of $6500 KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 DRG ",,," inpatient 8874.09 Aetna Commercial PPO 10031.04 fee schedule 7259.2 10031.04 100% of DRG fee schedule "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 DRG ",,," inpatient 20151.85 BCBS Louisiana PPO 20151.85 fee schedule 16484.65 20151.85 "Base Rate $7,946" "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 DRG ",,," inpatient 20151.85 Cigna Commercial PPO 16484.65 fee schedule 16484.65 20151.85 Base rate of $6500 "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 DRG ",,," inpatient 20151.85 Aetna Commercial PPO 19448.1 fee schedule 16484.65 20151.85 100% of DRG fee schedule "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 DRG ",,," inpatient 15943.65 BCBS Louisiana PPO 15943.65 fee schedule 13042.25 15943.65 "Base Rate $7,946" "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 DRG ",,," inpatient 15943.65 Cigna Commercial PPO 13042.25 fee schedule 13042.25 15943.65 Base rate of $6500 "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 DRG ",,," inpatient 15943.65 Aetna Commercial PPO 15271.74 fee schedule 13042.25 15943.65 100% of DRG fee schedule LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC 496 DRG ",,," inpatient 14333.79 BCBS Louisiana PPO 14333.79 fee schedule 11725.35 15981.3 "Base Rate $7,946" LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC 496 DRG ",,," inpatient 14333.79 Cigna Commercial PPO 11725.35 fee schedule 11725.35 15981.3 Base rate of $6500 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC 496 DRG ",,," inpatient 14333.79 Aetna Commercial PPO 15981.3 fee schedule 11725.35 15981.3 100% of DRG fee schedule LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC 497 DRG ",,," inpatient 9151.41 BCBS Louisiana PPO 9151.41 fee schedule 7486.05 10875.06 "Base Rate $7,946" LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC 497 DRG ",,," inpatient 9151.41 Cigna Commercial PPO 7486.05 fee schedule 7486.05 10875.06 Base rate of $6500 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC 497 DRG ",,," inpatient 9151.41 Aetna Commercial PPO 10875.06 fee schedule 7486.05 10875.06 100% of DRG fee schedule SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 DRG ",,," inpatient 10694.52 BCBS Louisiana PPO 10694.52 fee schedule 8748.35 11317.32 "Base Rate $7,946" SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 DRG ",,," inpatient 10694.52 Cigna Commercial PPO 8748.35 fee schedule 8748.35 11317.32 Base rate of $6500 SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 DRG ",,," inpatient 10694.52 Aetna Commercial PPO 11317.32 fee schedule 8748.35 11317.32 100% of DRG fee schedule "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC" 512 DRG ",,," inpatient 13153.81 BCBS Louisiana PPO 13153.81 fee schedule 10760.1 13153.81 "Base Rate $7,946" "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC" 512 DRG ",,," inpatient 13153.81 Cigna Commercial PPO 10760.1 fee schedule 10760.1 13153.81 Base rate of $6500 "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC" 512 DRG ",,," inpatient 13153.81 Aetna Commercial PPO 13023.18 fee schedule 10760.1 13153.81 100% of DRG fee schedule OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC 517 DRG ",,," inpatient 12210.62 BCBS Louisiana PPO 12210.62 fee schedule 9988.55 12210.62 "Base Rate $7,946" OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC 517 DRG ",,," inpatient 12210.62 Cigna Commercial PPO 9988.55 fee schedule 9988.55 12210.62 Base rate of $6500 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC 517 DRG ",,," inpatient 12210.62 Aetna Commercial PPO 12090.87 fee schedule 9988.55 12210.62 100% of DRG fee schedule BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR 518 DRG ",,," inpatient 29696.59 BCBS Louisiana PPO 29696.59 fee schedule 24292.45 29696.59 "Base Rate $7,946" BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR 518 DRG ",,," inpatient 29696.59 Cigna Commercial PPO 24292.45 fee schedule 24292.45 29696.59 Base rate of $6500 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR 518 DRG ",,," inpatient 29696.59 Aetna Commercial PPO 29030.4 fee schedule 24292.45 29696.59 100% of DRG fee schedule BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 519 DRG ",,," inpatient 15893.59 BCBS Louisiana PPO 15893.59 fee schedule 13001.3 15972.39 "Base Rate $7,946" BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 519 DRG ",,," inpatient 15893.59 Cigna Commercial PPO 13001.3 fee schedule 13001.3 15972.39 Base rate of $6500 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC 519 DRG ",,," inpatient 15893.59 Aetna Commercial PPO 15972.39 fee schedule 13001.3 15972.39 100% of DRG fee schedule BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC 520 DRG ",,," inpatient 11870.53 BCBS Louisiana PPO 11870.53 fee schedule 9710.35 11870.53 "Base Rate $7,946" BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC 520 DRG ",,," inpatient 11870.53 Cigna Commercial PPO 9710.35 fee schedule 9710.35 11870.53 Base rate of $6500 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC 520 DRG ",,," inpatient 11870.53 Aetna Commercial PPO 11608.92 fee schedule 9710.35 11870.53 100% of DRG fee schedule HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 DRG ",,," inpatient 16827.24 BCBS Louisiana PPO 16827.24 fee schedule 13765.05 17075.61 "Base Rate $7,946" HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 DRG ",,," inpatient 16827.24 Cigna Commercial PPO 13765.05 fee schedule 13765.05 17075.61 Base rate of $6500 HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 DRG ",,," inpatient 16827.24 Aetna Commercial PPO 17075.61 fee schedule 13765.05 17075.61 100% of DRG fee schedule MEDICAL BACK PROBLEMS WITHOUT MCC 552 DRG ",,," inpatient 7638.49 BCBS Louisiana PPO 7638.49 fee schedule 6248.45 7806.78 "Base Rate $7,946" MEDICAL BACK PROBLEMS WITHOUT MCC 552 DRG ",,," inpatient 7638.49 Cigna Commercial PPO 6248.45 fee schedule 6248.45 7806.78 Base rate of $6500 MEDICAL BACK PROBLEMS WITHOUT MCC 552 DRG ",,," inpatient 7638.49 Aetna Commercial PPO 7806.78 fee schedule 6248.45 7806.78 100% of DRG fee schedule BONE DISEASES AND ARTHROPATHIES WITHOUT MCC 554 DRG ",,," inpatient 6595.97 BCBS Louisiana PPO 6595.97 fee schedule 5395.65 6760.26 "Base Rate $7,946" BONE DISEASES AND ARTHROPATHIES WITHOUT MCC 554 DRG ",,," inpatient 6595.97 Cigna Commercial PPO 5395.65 fee schedule 5395.65 6760.26 Base rate of $6500 BONE DISEASES AND ARTHROPATHIES WITHOUT MCC 554 DRG ",,," inpatient 6595.97 Aetna Commercial PPO 6760.26 fee schedule 5395.65 6760.26 100% of DRG fee schedule "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC" 561 DRG ",,," inpatient 6387.79 BCBS Louisiana PPO 6387.79 fee schedule 5225.35 6622.56 "Base Rate $7,946" "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC" 561 DRG ",,," inpatient 6387.79 Cigna Commercial PPO 5225.35 fee schedule 5225.35 6622.56 Base rate of $6500 "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC" 561 DRG ",,," inpatient 6387.79 Aetna Commercial PPO 6622.56 fee schedule 5225.35 6622.56 100% of DRG fee schedule CELLULITIS WITHOUT MCC 603 DRG ",,," inpatient 6920.17 BCBS Louisiana PPO 6920.17 fee schedule 5660.85 7134.48 "Base Rate $7,946" CELLULITIS WITHOUT MCC 603 DRG ",,," inpatient 6920.17 Cigna Commercial PPO 5660.85 fee schedule 5660.85 7134.48 Base rate of $6500 CELLULITIS WITHOUT MCC 603 DRG ",,," inpatient 6920.17 Aetna Commercial PPO 7134.48 fee schedule 5660.85 7134.48 100% of DRG fee schedule POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC 858 DRG ",,," inpatient 11067.98 BCBS Louisiana PPO 11067.98 fee schedule 9053.85 11067.98 "Base Rate $7,946" POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC 858 DRG ",,," inpatient 11067.98 Cigna Commercial PPO 9053.85 fee schedule 9053.85 11067.98 Base rate of $6500 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC 858 DRG ",,," inpatient 11067.98 Aetna Commercial PPO 10436.04 fee schedule 9053.85 11067.98 100% of DRG fee schedule POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 DRG ",,," inpatient 7929.31 BCBS Louisiana PPO 7929.31 fee schedule 6486.35 8099.19 "Base Rate $7,946" POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 DRG ",,," inpatient 7929.31 Cigna Commercial PPO 6486.35 fee schedule 6486.35 8099.19 Base rate of $6500 POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 DRG ",,," inpatient 7929.31 Aetna Commercial PPO 8099.19 fee schedule 6486.35 8099.19 100% of DRG fee schedule WOUND DEBRIDEMENTS FOR INJURIES WITH CC 902 DRG ",,," inpatient 15212.62 BCBS Louisiana PPO 15212.62 fee schedule 12444.25 15370.56 "Base Rate $7,946" WOUND DEBRIDEMENTS FOR INJURIES WITH CC 902 DRG ",,," inpatient 15212.62 Cigna Commercial PPO 12444.25 fee schedule 12444.25 15370.56 Base rate of $6500 WOUND DEBRIDEMENTS FOR INJURIES WITH CC 902 DRG ",,," inpatient 15212.62 Aetna Commercial PPO 15370.56 fee schedule 12444.25 15370.56 100% of DRG fee schedule WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC 903 DRG ",,," inpatient 9293.64 BCBS Louisiana PPO 9293.64 fee schedule 7602.4 9874.71 "Base Rate $7,946" WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC 903 DRG ",,," inpatient 9293.64 Cigna Commercial PPO 7602.4 fee schedule 7602.4 9874.71 Base rate of $6500 WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC 903 DRG ",,," inpatient 9293.64 Aetna Commercial PPO 9874.71 fee schedule 7602.4 9874.71 100% of DRG fee schedule OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 DRG ",,," inpatient 15853.86 BCBS Louisiana PPO 15853.86 fee schedule 12968.8 16338.51 "Base Rate $7,946" OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 DRG ",,," inpatient 15853.86 Cigna Commercial PPO 12968.8 fee schedule 12968.8 16338.51 Base rate of $6500 OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 DRG ",,," inpatient 15853.86 Aetna Commercial PPO 16338.51 fee schedule 12968.8 16338.51 100% of DRG fee schedule OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC 909 DRG ",,," inpatient 10430.71 BCBS Louisiana PPO 10430.71 fee schedule 8532.55 10430.71 "Base Rate $7,946" OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC 909 DRG ",,," inpatient 10430.71 Cigna Commercial PPO 8532.55 fee schedule 8532.55 10430.71 Base rate of $6500 OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC 909 DRG ",,," inpatient 10430.71 Aetna Commercial PPO 10273.23 fee schedule 8532.55 10430.71 100% of DRG fee schedule COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 DRG ",,," inpatient 5470.03 BCBS Louisiana PPO 5470.03 fee schedule 4474.6 5570.37 "Base Rate $7,946" COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 DRG ",,," inpatient 5470.03 Cigna Commercial PPO 4474.6 fee schedule 4474.6 5570.37 Base rate of $6500 COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 DRG ",,," inpatient 5470.03 Aetna Commercial PPO 5570.37 fee schedule 4474.6 5570.37 100% of DRG fee schedule O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC 941 DRG ",,," inpatient 16112.1 BCBS Louisiana PPO 16112.1 fee schedule 13180.05 16112.1 "Base Rate $7,946" O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC 941 DRG ",,," inpatient 16112.1 Cigna Commercial PPO 13180.05 fee schedule 13180.05 16112.1 Base rate of $6500 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC 941 DRG ",,," inpatient 16112.1 Aetna Commercial PPO 15829.83 fee schedule 13180.05 16112.1 100% of DRG fee schedule SIGNS AND SYMPTOMS WITHOUT MCC 948 DRG ",,," inpatient 6360.77 BCBS Louisiana PPO 6360.77 fee schedule 5203.25 6435.45 "Base Rate $7,946" SIGNS AND SYMPTOMS WITHOUT MCC 948 DRG ",,," inpatient 6360.77 Cigna Commercial PPO 5203.25 fee schedule 5203.25 6435.45 Base rate of $6500 SIGNS AND SYMPTOMS WITHOUT MCC 948 DRG ",,," inpatient 6360.77 Aetna Commercial PPO 6435.45 fee schedule 5203.25 6435.45 100% of DRG fee schedule OTHER FACTORS INFLUENCING HEALTH STATUS 951 DRG ",,," inpatient 4417.98 BCBS Louisiana PPO 4417.98 fee schedule 3614 4592.7 "Base Rate $7,946" OTHER FACTORS INFLUENCING HEALTH STATUS 951 DRG ",,," inpatient 4417.98 Cigna Commercial PPO 3614 fee schedule 3614 4592.7 Base rate of $6500 OTHER FACTORS INFLUENCING HEALTH STATUS 951 DRG ",,," inpatient 4417.98 Aetna Commercial PPO 4592.7 fee schedule 3614 4592.7 100% of DRG fee schedule