hospital_name,last_updated_on,version,hospital_location,hospital_address,financial_aid_policy,license_number|NV,"To the best of its knowledge and belief, the 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 indicated."
Renown_South_Meadows_Medical_Center,7/1/2024,1.1.0,Renown_South_Meadows_Medical_Center,"10101 Double R Blvd, Reno, NV 89521","Uninsured Patients with Federal Poverty Level less than 400 percent of the Federal Poverty Guidelines will be considered for the Financial Assistance Program. Patients with Federal Poverty Level greater than 400 percent of the Poverty Guidelines can be evaluated for a payment plan. Insured patients are required to apply for government program assistance if under 138% FPL. A payment, denial (denials due to lack of patient cooperation will not be considered), or benefit summary from primary insurance must be secured prior to consideration of Financial Assistance eligibility. Insured patients up to 100 percent of Federal Poverty Guidelines will be considered for the Financial Assistance Program regardless of the account balance. Insured patients 101 percent to 400 percent of Federal Poverty Guidelines will be considered for the Financial Assistance Program. All patients are required to make a financial contribution towards their bill. Patients are subject to co-pay and/or cost share amount based on their specific Federal Poverty Level and Federal Poverty Guideline matrix. Patient co-pay amounts are to be paid in full when a statement for the amount is received. If approval is granted by Financial Assistance, copayments not paid will follow the normal billing process. https://www.renown.org/patients-and-visitors/billing/financial-assistance/",46-0517825 | NV,TRUE
description,code | 1 ,code | 2,code | 3,code | 1 | type,code | 2 | type,code | 3 | type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,modifiers,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percent,standard_charge|negotiated_algorithm,estimated_amount,standard_charge|min,standard_charge|max,standard_charge|contracting_method,additional_generic_notes
"HCHG ROOM/CARE - MED/SURG/GYN PRIV*",0111,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - ISO PRIVATE",0111,,,RC,,,FACILITY,INPATIENT,,,,2970.00 ,2079.00 ,Aetna,"AETNA",7684.00,,per diem,999999999,1075.14,7684,per diem,""
"HCHG ROOM/CARE - NEGATIVE PRESSURE ISOLATION",0111,,,RC,,,FACILITY,INPATIENT,,,,4249.00 ,2974.30 ,Aetna,"AETNA",7684.00,,per diem,999999999,1538,7684,per diem,""
"HCHG ROOM/CARE - OB PRIVATE (112)",0112,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - PEDIATRIC PRIVATE*",0113,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - ISO PRIVATE",0113,,,RC,,,FACILITY,INPATIENT,,,,2970.00 ,2079.00 ,Aetna,"AETNA",7684.00,,per diem,999999999,1075.14,7684,per diem,""
"HCHG ROOM/CARE - ONCOLOGY PRIVATE *",0117,,,RC,,,FACILITY,INPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",7684.00,,per diem,999999999,1040.75,7684,per diem,""
"HCHG ROOM/CARE - REHAB PRIVATE (11*",0118,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",2856.00,,per diem,999999999,760,4829,per diem,""
"HCHG ROOM/CARE - MED/SURG/GYN SEMI*",0121,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - ISO SEMI PRIVATE",0121,,,RC,,,FACILITY,INPATIENT,,,,2970.00 ,2079.00 ,Aetna,"AETNA",7684.00,,per diem,999999999,1075.14,7684,per diem,""
"HCHG ROOM/CARE - OB SEMI PRIVATE (*",0122,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - PEDIATRIC SEMI PR*",0123,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - PICU SEMI PRIVATE*",0123,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",7684.00,,per diem,999999999,977.762,7684,per diem,""
"HCHG ROOM/CARE - ONCOLOGY SEMI PRI*",0127,,,RC,,,FACILITY,INPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",7684.00,,per diem,999999999,1040.75,7684,per diem,""
"HCHG ROOM/CARE - REHAB SEMI PRIVAT*",0128,,,RC,,,FACILITY,INPATIENT,,,,2701.00 ,1890.70 ,Aetna,"AETNA",2856.00,,per diem,999999999,760,4829,per diem,""
"HCHG ROOM/CARE - WARD (150)",0150,,,RC,,,FACILITY,INPATIENT,,,,1729.00 ,1210.30 ,Aetna,"AETNA",7684.00,,per diem,999999999,625.898,7684,per diem,""
"HCHG ROOM/CARE - NEWBORN LEVEL 1 (*",0171,,,RC,,,FACILITY,INPATIENT,,,,1532.00 ,1072.40 ,Aetna,"AETNA",7684.00,,per diem,999999999,0,7684,per diem,""
"HCHG ROOM/CARE - NEWBORN LEVEL 2 (*",0172,,,RC,,,FACILITY,INPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",7684.00,,per diem,999999999,408,7969.42,per diem,""
"HCHG ROOM/CARE - NEWBORN LEVEL 3 (*",0173,,,RC,,,FACILITY,INPATIENT,,,,4737.00 ,3315.90 ,Aetna,"AETNA",7684.00,,per diem,999999999,1714.794,9005.72,per diem,""
"HCHG ROOM/CARE - NEWBORN LEVEL 4 (*",0174,,,RC,,,FACILITY,INPATIENT,,,,5229.00 ,3660.30 ,Aetna,"AETNA",7684.00,,per diem,999999999,1858,9005.72,per diem,""
"HCHG ROOM/CARE - ICU (200)",0200,,,RC,,,FACILITY,INPATIENT,,,,4926.00 ,3448.20 ,Aetna,"AETNA",9048.00,,per diem,999999999,1538,9048,per diem,""
"HCHG ROOM/CARE - PEDIATRIC ICU (20*",0203,,,RC,,,FACILITY,INPATIENT,,,,5229.00 ,3660.30 ,Aetna,"AETNA",9048.00,,per diem,999999999,1538,9048,per diem,""
"HCHG ROOM/CARE - INTERMEDIATE ICU *",0206,,,RC,,,FACILITY,INPATIENT,,,,4249.00 ,2974.30 ,Aetna,"AETNA",8007.00,,per diem,999999999,1538,8007,per diem,""
"HCHG ROOM/CARE - TELE (206)",0206,,,RC,,,FACILITY,INPATIENT,,,,4249.00 ,2974.30 ,Aetna,"AETNA",8007.00,,per diem,999999999,1538,8007,per diem,""
"HCHG ROOM/CARE - PACU ICU OVERFLOW",0206,,,RC,,,FACILITY,INPATIENT,,,,4926.00 ,3448.20 ,Aetna,"AETNA",8007.00,,per diem,999999999,1538,8007,per diem,""
"SYRINGE QS WITH D10W",0220,,99999706699,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MENING VAC SERO B 2-3 DOSE SCHED IM",0250,90621,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",370.43,191,fee schedule,999999999,21,370.4254,fee schedule,"191% of Drug Fee Schedule"
"HCHG HEPA VACCINE PED/ADOL-2 DOSE",0250,90633,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,158.00 ,110.60 ,Aetna,"AETNA",74.99,191,fee schedule,999999999,34.85,110.6,fee schedule,"191% of Drug Fee Schedule"
"HCHG HIB VACCINE, PRP-OMP, IM",0250,90647,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,159.00 ,111.30 ,Aetna,"AETNA",58.31,191,fee schedule,999999999,28.87,111.3,fee schedule,"191% of Drug Fee Schedule"
"HCHG HIB VACCINE, PRP-T, IM",0250,90648,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",24.91,191,fee schedule,999999999,12.29,49,fee schedule,"191% of Drug Fee Schedule"
"HCHG 9VHPV VACCINE 2-3 DOSE IM",0250,90651,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",559.94,191,fee schedule,999999999,268.77,630,fee schedule,"191% of Drug Fee Schedule"
"HCHG ROTOVIRUS VACCINE, PENTAVAL, 3 DOSE, ORAL",0250,90680,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",186.70,191,fee schedule,999999999,21,186.7025,fee schedule,"191% of Drug Fee Schedule"
"HCHG DTAP-IPV, IM, AGE 4-6 YEAR",0250,90696,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",123.58,191,fee schedule,999999999,21,123.577,fee schedule,"191% of Drug Fee Schedule"
"HCHG DTAP-IPV-HIB-HEPB VACCINE IM",0250,90697,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",302.75,191,fee schedule,999999999,21,302.7541,fee schedule,"191% of Drug Fee Schedule"
"HCHG DTAP-HIB-IP VACCINE, IM",0250,90698,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",232.35,191,fee schedule,999999999,21,232.3515,fee schedule,"191% of Drug Fee Schedule"
"HCHG DTAP IMMUNIZATION, IM, <7 YO",0250,90700,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",57.97,191,fee schedule,999999999,21,57.9685,fee schedule,"191% of Drug Fee Schedule"
"HCHG MMR VIRUS IMMUNIZATION, SUBCUT",0250,90707,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",185.80,191,fee schedule,999999999,21,185.8048,fee schedule,"191% of Drug Fee Schedule"
"HCHG COMBINED VACCINE,MMR+VARICELLA,SUB-Q",0250,90710,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",525.33,191,fee schedule,999999999,262.37,630,fee schedule,"191% of Drug Fee Schedule"
"HCHG POLIOMYELITIS IMMUNIZATN,INACTV,SUB-Q",0250,90713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",86.73,191,fee schedule,999999999,21,86.7331,fee schedule,"191% of Drug Fee Schedule"
"HCHG CHICKEN POX VACCINE,LIVE,SUB-Q",0250,90716,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",339.37,191,fee schedule,999999999,159.99,630,fee schedule,"191% of Drug Fee Schedule"
"HCHG DTAP/HEPB/IPV VACCINE,IM",0250,90723,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",198.56,191,fee schedule,999999999,21,198.5636,fee schedule,"191% of Drug Fee Schedule"
"HCHG MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE",0250,90734,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",306.31,191,fee schedule,999999999,21,306.3067,fee schedule,"191% of Drug Fee Schedule"
"HCHG HEP B VACCINE,PED/ADOL,IM",0250,90744,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",58.77,191,fee schedule,999999999,21,58.7707,fee schedule,"191% of Drug Fee Schedule"
"HCHG VFC PCV20 VACCINE FOR INTRAMUSCULAR USE",0250,90677,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,0.01 ,0.01 ,Aetna,"AETNA",569.26,191,fee schedule,999999999,0.003,569.2564,fee schedule,"191% of Drug Fee Schedule"
"HCHG VFC PNEUMOCOCCAL VACCINE,23-VALENT,ADULT",0250,90732,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,0.01 ,0.01 ,Aetna,"AETNA",254.93,191,fee schedule,999999999,0.003,254.9277,fee schedule,"191% of Drug Fee Schedule"
"HCHG VFC HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM NJX",0250,90750,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,0.01 ,0.01 ,Aetna,"AETNA",385.53,191,fee schedule,999999999,0.003,385.5335,fee schedule,"191% of Drug Fee Schedule"
"HCHG RSV MONOC ANTB SEASN .5ML IM",0250,90380,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",964.36,191,fee schedule,999999999,270,964.359,fee schedule,"191% of Drug Fee Schedule"
"HCHG RSV MONOC ANTB SEASN 1 ML IM",0250,90381,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",964.36,191,fee schedule,999999999,270,964.359,fee schedule,"191% of Drug Fee Schedule"
"HCHG RSV VACC PREF SUBUNIT BIVAL IM",0250,90678,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",574.72,191,fee schedule,999999999,225,630,fee schedule,"191% of Drug Fee Schedule"
"HCHG DEPO PROVERA PER MG",0250,J1050,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,0.01,0.01 ,Aetna,"AETNA",1.24,191,fee schedule,999999999,0.003,1.2415,fee schedule,"191% of Drug Fee Schedule"
"HCHG SHINGRIX VACCINE",0250,90750,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",385.53,191,fee schedule,999999999,181.86,630,fee schedule,"191% of Drug Fee Schedule"
"HCHG INO CONTINUOUS Q2H",0250,,,RC,,,FACILITY,OUTPATIENT,,,,1784.00 ,1248.80 ,Aetna,"AETNA",802.80,45,percent of total billed charges,999999999,535.2,1248.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HELIOX Q2H",0250,,,RC,,,FACILITY,OUTPATIENT,,,,372.00 ,260.40 ,Aetna,"AETNA",167.40,45,percent of total billed charges,999999999,111.6,260.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PNEUMOCOCCAL CONJUGATE VALENT 13",0250,90670,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,160.00 ,112.00 ,Aetna,"AETNA",492.76,191,fee schedule,999999999,48,492.7609,fee schedule,"191% of Drug Fee Schedule"
"HCHG PNEUMOCOCCAL VACCINE VALENT 23",0250,90732,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,126.00 ,88.20 ,Aetna,"AETNA",254.93,191,fee schedule,999999999,37.8,254.9277,fee schedule,"191% of Drug Fee Schedule"
"HCHG FLUZONE HD VACCINE (SPLIT VIRUS PF)",0250,90662,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,82.00 ,57.40 ,Aetna,"AETNA",140.19,191,fee schedule,999999999,24.6,140.194,fee schedule,"191% of Drug Fee Schedule"
"HCHG FLU VACCINE QUAD (SPLIT VIRUS PF)",0250,90686,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,40.00 ,28.00 ,Aetna,"AETNA",42.69,191,fee schedule,999999999,12,42.6885,fee schedule,"191% of Drug Fee Schedule"
"HCHG INFLUENZA VACCINE, SPLIT VIRUS",0250,Q2038,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,43.00 ,30.10 ,Aetna,"AETNA",24.22,191,fee schedule,999999999,0.01,30.1,fee schedule,"191% of Drug Fee Schedule"
"HCHG ZOSTER(SHINGLES)VACC LIVE SQ",0250,90736,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,233.00 ,163.10 ,Aetna,"AETNA",414.32,191,fee schedule,999999999,0.01,414.3172,fee schedule,"191% of Drug Fee Schedule"
"HCHG TDAP VACCINE(AGE>=7)",0250,90715,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",74.66,191,fee schedule,999999999,21,74.6619,fee schedule,"191% of Drug Fee Schedule"
"HCHG RHO IMMUNOGLOBULIN INJ 300 MCG BLD",0250,J2790,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,122.00 ,85.40 ,Aetna,"AETNA",152.76,191,fee schedule,999999999,36.6,152.7618,fee schedule,"191% of Drug Fee Schedule"
"HCHG SURGIFLO",0250,,,RC,,,FACILITY,OUTPATIENT,,,,737.00 ,515.90 ,Aetna,"AETNA",331.65,45,percent of total billed charges,999999999,221.1,515.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SOLUTION BSS 500ML",0250,,,RC,,,FACILITY,OUTPATIENT,,,,36.00 ,25.20 ,Aetna,"AETNA",16.20,45,percent of total billed charges,999999999,10.8,25.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SOLUTION SORBITOL 3% 3000ML BAG",0250,,,RC,,,FACILITY,OUTPATIENT,,,,57.00 ,39.90 ,Aetna,"AETNA",25.65,45,percent of total billed charges,999999999,17.1,39.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG IV DIPYRIDAMOLE PER 10MG",0250,J1245,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",7.14,191,fee schedule,999999999,3.69,34.3,fee schedule,"191% of Drug Fee Schedule"
"HCHG SINCALIDE CCK KINEVAC INJ 5 MCG",0250,J2805,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,682.00 ,477.40 ,Aetna,"AETNA",247.80,191,fee schedule,999999999,123.16,477.4,fee schedule,"191% of Drug Fee Schedule"
"BENZTROPINE MESYLATE 2 MG PO TABS",0250,A9270,64125013801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETOPOSIDE 50 MG PO CAPS",0250,J8560,00378326694,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,1908.24 ,1335.77 ,Aetna,"AETNA",146.10,191,fee schedule,999999999,76.03,1335.768,fee schedule,"191% of Drug Fee Schedule"
"ALTEPLASE 1 MG/ML IN SYRINGE",0250,J2997,99999053599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,220.74 ,154.52 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,66.222,169.6462,fee schedule,"191% of Drug Fee Schedule"
"SIROLIMUS 0.5 MG PO TABS",0250,J7520,67877074601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,25.34 ,17.74 ,Aetna,"AETNA",4.70,191,fee schedule,999999999,2.67,17.738,fee schedule,"191% of Drug Fee Schedule"
"FAMOTIDINE 10 MG/ML IV SOLN (WRAPPED)",0250,J3490,63323073911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN (WRAPPED)",0250,J3490,63323073806,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN (WRAPPED)",0250,J3490,63323073820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN (WRAPPED)",0250,J3490,63323073912,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 40 MG/5ML PO SUSR",0250,A9270,70954031610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 20 MG PO TABS",0250,A9270,00172572860,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FELBAMATE 600 MG/5ML PO SUSP",0250,A9270,51525044208,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,357.33 ,250.13 ,Aetna,"AETNA",160.80,45,percent of total billed charges,999999999,0.03087,250.131,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EVEROLIMUS 0.25 MG PO TABS",0250,J7527,67877071831,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,27.15 ,19.01 ,Aetna,"AETNA",5.12,191,fee schedule,999999999,2.751,19.005,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 300 MCG/ML INJ SOLN",0250,J1442,55513053001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1343.92 ,940.74 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1073.296,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 300 MCG/ML INJ SOLN",0250,J1442,55513053010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1533.28 ,1073.30 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1073.296,fee schedule,"191% of Drug Fee Schedule"
"FINASTERIDE 5 MG PO TABS",0250,A9270,00904683061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLECAINIDE ACETATE 100 MG PO TABS",0250,A9270,65162064210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,4.991,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLECAINIDE ACETATE 100 MG PO TABS",0250,A9270,00054001125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.13 ,4.99 ,Aetna,"AETNA",3.21,45,percent of total billed charges,999999999,0.03087,4.991,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLECAINIDE ACETATE 150 MG PO TABS",0250,A9270,53746064301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLECAINIDE ACETATE 50 MG PO TABS",0250,A9270,00054001020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE 100 MG PO TABS",0250,A9270,00904650006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE 200 MG PO TABS",0250,A9270,00904650106,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE 50 MG PO TABS",0250,A9270,00172541046,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE 50 MG PO TABS",0250,A9270,68462010130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN",0250,J1450,25021018482,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,25.90 ,18.13 ,Aetna,"AETNA",5.29,191,fee schedule,999999999,2.31,18.13,fee schedule,"191% of Drug Fee Schedule"
"LACTULOSE 20 GM/30ML PO SOLN",0250,A9270,00121115430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,7.92 ,5.54 ,Aetna,"AETNA",3.56,45,percent of total billed charges,999999999,0.03087,5.544,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE 20 GM/30ML PO SOLN",0250,A9270,00121115440,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.46 ,3.82 ,Aetna,"AETNA",2.46,45,percent of total billed charges,999999999,0.03087,5.544,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE 20 GM/30ML PO SOLN",0250,A9270,99999062099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.544,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN",0250,J1450,25021018487,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,28.00 ,19.60 ,Aetna,"AETNA",5.29,191,fee schedule,999999999,2.31,19.6,fee schedule,"191% of Drug Fee Schedule"
"FLUCYTOSINE 500 MG PO CAPS",0250,A9270,59651033201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,114.74 ,80.32 ,Aetna,"AETNA",51.63,45,percent of total billed charges,999999999,0.03087,80.318,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUDARABINE PHOSPHATE 50 MG IV SOLR",0250,J9185,00703585401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,691.68 ,484.18 ,Aetna,"AETNA",364.62,191,fee schedule,999999999,92.21,604.75,fee schedule,"191% of Drug Fee Schedule"
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS",0250,A9270,50268033015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUDROCORTISONE ACETATE 0.1 MG PO TABS",0250,A9270,50268033011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GATIFLOXACIN 0.5 % OP SOLN",0250,,00023361525,RC,,NDC,FACILITY,OUTPATIENT,2.5,ML,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACOSAMIDE 10 MG/ML PO SOLN",0250,A9270,70954048810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUORESCEIN-BENOXINATE 0.25-0.4 % OP SOLN",0250,A9270,59390021805,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,122.88 ,86.02 ,Aetna,"AETNA",55.30,45,percent of total billed charges,999999999,0.03087,86.016,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOXETINE HCL 10 MG PO CAPS",0250,A9270,65862019201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOXETINE HCL 20 MG PO CAPS",0250,A9270,00904734661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CABAZITAXEL 60 MG/1.5ML IV SOLN",0250,J9043,00024582411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,165797.41 ,116058.19 ,Aetna,"AETNA",404.46,191,fee schedule,999999999,195.65,116058.187,fee schedule,"191% of Drug Fee Schedule"
"FLURBIPROFEN SODIUM 0.03 % OP SOLN",0250,,69292072225,RC,,NDC,FACILITY,OUTPATIENT,2.5,ML,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,63,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOMETASONE FURO-FORMOTEROL FUM 100-5 MCG/ACT INH AERO",0250,A9270,78206012702,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,335.23 ,234.66 ,Aetna,"AETNA",150.85,45,percent of total billed charges,999999999,0.03087,234.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOMETASONE FURO-FORMOTEROL FUM 200-5 MCG/ACT INH AERO",0250,A9270,78206012602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,335.23 ,234.66 ,Aetna,"AETNA",150.85,45,percent of total billed charges,999999999,0.03087,234.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUVOXAMINE MALEATE 50 MG PO TABS",0250,A9270,62559015901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 325 MG PO TABS",0250,A9270,00904677361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GANCICLOVIR SODIUM 500 MG IV SOLR",0250,J1570,70436008955,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,176.26 ,123.38 ,Aetna,"AETNA",84.23,191,fee schedule,999999999,29.99,123.382,fee schedule,"191% of Drug Fee Schedule"
"GLIPIZIDE 10 MG PO TABS",0250,A9270,60505014200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIPIZIDE 5 MG PO TABS",0250,A9270,00904663761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYBURIDE 2.5 MG PO TABS",0250,A9270,51079087201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYBURIDE 2.5 MG PO TABS",0250,A9270,51079087220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCOPYRROLATE 1 MG PO TABS",0250,A9270,23155060601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GOSERELIN ACETATE 3.6 MG SC IMPL",0250,J9202,70720095036,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.6,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",1144.74,191,fee schedule,999999999,572.72,2100,fee schedule,"191% of Drug Fee Schedule"
"GUANFACINE HCL 1 MG PO TABS",0250,A9270,00904714004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.26 ,7.18 ,Aetna,"AETNA",4.62,45,percent of total billed charges,999999999,0.03087,7.182,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INCOBOTULINUMTOXINA 100 UNITS IM SOLR",0250,J0588,00259161001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2480.00 ,1736.00 ,Aetna,"AETNA",9.93,191,fee schedule,999999999,5.05,1736,fee schedule,"191% of Drug Fee Schedule"
"HALOPERIDOL DECANOATE 50 MG/ML IM SOLN",0250,J1631,70069003001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,38.84 ,27.19 ,Aetna,"AETNA",12.89,191,fee schedule,999999999,7.32,27.188,fee schedule,"191% of Drug Fee Schedule"
"HALOPERIDOL DECANOATE 50 MG/ML IM SOLN",0250,J1631,70069003003,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,38.84 ,27.19 ,Aetna,"AETNA",12.89,191,fee schedule,999999999,7.32,27.188,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN",0250,J1644,63323054005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN",0250,J1644,63323054015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN",0250,J1644,63323054033,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN",0250,J1644,63323054036,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 10000 UNIT/ML INJ SOLN",0250,J1644,63323054201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,18.69 ,13.08 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,13.083,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML INJ SOLN",0250,J1644,63323026203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,6.93 ,4.85 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,4.851,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN SODIUM (PORCINE) 5000 UNIT/ML INJ SOLN",0250,J1644,63323026206,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,6.93 ,4.85 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,4.851,fee schedule,"191% of Drug Fee Schedule"
"ONDANSETRON HCL 4 MG/2ML INJ SOLN",0250,J2405,60505613000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.09,3.5,fee schedule,"191% of Drug Fee Schedule"
"ONDANSETRON HCL 4 MG/2ML INJ SOLN",0250,J2405,60505613005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.09,3.5,fee schedule,"191% of Drug Fee Schedule"
"AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR",0250,J0295,55150011899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.5,GR,,151.86 ,106.30 ,Aetna,"AETNA",4.05,191,fee schedule,999999999,1.769,106.302,fee schedule,"191% of Drug Fee Schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 INJ SOLN",0250,,00409174630,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,10.43 ,7.30 ,Aetna,"AETNA",4.69,45,percent of total billed charges,999999999,2.898,18.179,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 INJ SOLN",0250,,00409904201,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,25.97 ,18.18 ,Aetna,"AETNA",11.69,45,percent of total billed charges,999999999,2.898,18.179,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 INJ SOLN",0250,,00409174671,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,9.66 ,6.76 ,Aetna,"AETNA",4.35,45,percent of total billed charges,999999999,2.898,18.179,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 INJ SOLN",0250,,00409174929,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.32 ,3.72 ,Aetna,"AETNA",2.39,45,percent of total billed charges,999999999,1.5,7.903,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 INJ SOLN",0250,,00409904501,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,7.70 ,5.39 ,Aetna,"AETNA",3.47,45,percent of total billed charges,999999999,1.5,7.903,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 INJ SOLN",0250,,00409174971,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,7.903,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 INJ SOLN",0250,,99999024999,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,11.29 ,7.90 ,Aetna,"AETNA",5.08,45,percent of total billed charges,999999999,1.5,7.903,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE HCL (PF) 0.25 % INJ SOLN",0250,J0665,55150016710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,7.60 ,5.32 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,5.733,fee schedule,"191% of Drug Fee Schedule"
"BUPIVACAINE HCL (PF) 0.25 % INJ SOLN",0250,J0665,55150016830,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,8.19 ,5.73 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,5.733,fee schedule,"191% of Drug Fee Schedule"
"BUPIVACAINE HCL (PF) 0.5 % INJ SOLN",0250,J0665,55150016910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,8.00 ,5.60 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,6.027,fee schedule,"191% of Drug Fee Schedule"
"BUPIVACAINE HCL (PF) 0.5 % INJ SOLN",0250,J0665,55150017030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,8.61 ,6.03 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,6.027,fee schedule,"191% of Drug Fee Schedule"
"ACETAMINOPHEN 500 MG PO TABS",0250,A9270,50580045711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP",0250,,24208083060,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,75.96 ,53.17 ,Aetna,"AETNA",34.18,45,percent of total billed charges,999999999,22.788,53.172,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT",0250,,24208079535,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,78.67 ,55.07 ,Aetna,"AETNA",35.40,45,percent of total billed charges,999999999,23.601,55.069,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN",0250,J0257,00944288401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1470.00 ,1029.00 ,Aetna,"AETNA",10.31,191,fee schedule,999999999,5.18,1029,fee schedule,"191% of Drug Fee Schedule"
"ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN",0250,J0257,00944288402,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1470.00 ,1029.00 ,Aetna,"AETNA",10.31,191,fee schedule,999999999,5.18,1029,fee schedule,"191% of Drug Fee Schedule"
"HYDROCORTISONE 5 MG PO TABS",0250,A9270,00115169606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 100 MG/60ML PR ENEM",0250,A9270,62559013807,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,ML,,41.58 ,29.11 ,Aetna,"AETNA",18.71,45,percent of total billed charges,999999999,0.03087,29.106,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONDANSETRON HCL 40 MG/20ML INJ SOLN",0250,J2405,00409475901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8.12 ,5.68 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.09,5.684,fee schedule,"191% of Drug Fee Schedule"
"DOCETAXEL 20 MG/ML IV CONC",0250,J9171,00955102001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,420.66 ,294.46 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,294.462,fee schedule,"191% of Drug Fee Schedule"
"DOCETAXEL 20 MG/ML IV CONC",0250,J9171,16729026763,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,157.98 ,110.59 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,294.462,fee schedule,"191% of Drug Fee Schedule"
"DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS",0250,A9270,00597035556,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,20.48 ,14.34 ,Aetna,"AETNA",9.22,45,percent of total billed charges,999999999,0.03087,14.336,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS",0250,A9270,00597036082,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,20.48 ,14.34 ,Aetna,"AETNA",9.22,45,percent of total billed charges,999999999,0.03087,14.336,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS",0250,A9270,43598072101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYUREA 500 MG PO CAPS",0250,A9270,00904693961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.87 ,4.11 ,Aetna,"AETNA",2.64,45,percent of total billed charges,999999999,0.03087,4.109,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 100 MG/5ML PO SUSP",0250,A9270,68094049461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,6.84 ,4.79 ,Aetna,"AETNA",3.08,45,percent of total billed charges,999999999,0.03087,4.788,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 100 MG/5ML PO SUSP",0250,A9270,68094049459,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,6.48 ,4.54 ,Aetna,"AETNA",2.92,45,percent of total billed charges,999999999,0.03087,4.788,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 100 MG/5ML PO SUSP",0250,A9270,50580060121,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,4.788,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IFOSFAMIDE 3 G IV SOLR",0250,J9208,10019092602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,519.90 ,363.93 ,Aetna,"AETNA",50.52,191,fee schedule,999999999,25.38,363.93,fee schedule,"191% of Drug Fee Schedule"
"ABOBOTULINUMTOXINA 300 UNITS IM SOLR",0250,J0586,15054053006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,2500.00 ,1750.00 ,Aetna,"AETNA",16.58,191,fee schedule,999999999,8.22,1750,fee schedule,"191% of Drug Fee Schedule"
"ERIBULIN MESYLATE 1 MG/2ML IV SOLN",0250,J9179,62856038901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,4088.40 ,2861.88 ,Aetna,"AETNA",262.95,191,fee schedule,999999999,125.68,2861.88,fee schedule,"191% of Drug Fee Schedule"
"FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR",0250,J1453,71839010401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,93.00 ,65.10 ,Aetna,"AETNA",0.25,191,fee schedule,999999999,0.12,65.1,fee schedule,"191% of Drug Fee Schedule"
"AQUADEKS PO CHEW",0250,A9270,58914001460,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.05 ,7.04 ,Aetna,"AETNA",4.52,45,percent of total billed charges,999999999,0.03087,7.035,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DENOSUMAB 120 MG/1.7ML SC SOLN",0250,J0897,55513073001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8922.12 ,6245.48 ,Aetna,"AETNA",48.11,191,fee schedule,999999999,22.51,6245.484,fee schedule,"191% of Drug Fee Schedule"
"INDOMETHACIN SODIUM 1 MG IV SOLR",0250,,63323065903,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,1336.60 ,935.62 ,Aetna,"AETNA",601.47,45,percent of total billed charges,999999999,400.98,935.62,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BETAMETHASONE DIPROPIONATE 0.05 % EX CREA",0250,A9270,00168005515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,153.00 ,107.10 ,Aetna,"AETNA",68.85,45,percent of total billed charges,999999999,0.03087,107.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP",0250,J1815,00002831501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,83.58 ,58.51 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,58.506,fee schedule,"191% of Drug Fee Schedule"
"INSULIN NPH ISOPHANE & REGULAR (70-30) 100 UNIT/ML SC SUSP",0250,J1815,00002871501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,97.44 ,68.21 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,68.208,fee schedule,"191% of Drug Fee Schedule"
"INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN",0250,J1815,00002821501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,83.58 ,58.51 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,58.506,fee schedule,"191% of Drug Fee Schedule"
"INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN",0250,J1815,00002021301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,31.50 ,22.05 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,58.506,fee schedule,"191% of Drug Fee Schedule"
"BETAMETHASONE DIPROPIONATE 0.05 % EX OINT",0250,A9270,72578009301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,130.68 ,91.48 ,Aetna,"AETNA",58.81,45,percent of total billed charges,999999999,0.03087,91.476,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTERFERON ALFA-2B 10000000 UNITS INJ SOLR",0250,J9214,00085057102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,Million Units,,1008.35 ,705.85 ,Aetna,"AETNA",70.44,191,fee schedule,999999999,31.35,705.845,fee schedule,"191% of Drug Fee Schedule"
"ACETAMINOPHEN 120 MG PR SUPP",0250,A9270,45802073233,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTERFERON ALFA-2B 18000000 UNITS INJ SOLR",0250,J9214,00085006102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,Million Units,,1840.75 ,1288.53 ,Aetna,"AETNA",70.44,191,fee schedule,999999999,31.35,1288.525,fee schedule,"191% of Drug Fee Schedule"
"INTERFERON ALFA-2B 18000000 UNITS INJ SOLR",0250,J9214,00085111001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,Million Units,,1840.75 ,1288.53 ,Aetna,"AETNA",70.44,191,fee schedule,999999999,31.35,1288.525,fee schedule,"191% of Drug Fee Schedule"
"BUPRENORPHINE 5 MCG/HR TD PTWK",0250,A9270,59011075004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,262.83 ,183.98 ,Aetna,"AETNA",118.27,45,percent of total billed charges,999999999,0.03087,183.981,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 5 MCG/HR TD PTWK",0250,A9270,00093365621,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,205.65 ,143.96 ,Aetna,"AETNA",92.54,45,percent of total billed charges,999999999,0.03087,183.981,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 5 MCG/HR TD PTWK",0250,A9270,00093365640,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,205.65 ,143.96 ,Aetna,"AETNA",92.54,45,percent of total billed charges,999999999,0.03087,183.981,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 10 MCG/HR TD PTWK",0250,A9270,00093365721,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,289.19 ,202.43 ,Aetna,"AETNA",130.14,45,percent of total billed charges,999999999,0.03087,208.985,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 10 MCG/HR TD PTWK",0250,A9270,00093365740,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,298.55 ,208.99 ,Aetna,"AETNA",134.35,45,percent of total billed charges,999999999,0.03087,208.985,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 20 MCG/HR TD PTWK",0250,A9270,00093365921,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,683.57 ,478.50 ,Aetna,"AETNA",307.61,45,percent of total billed charges,999999999,0.03087,478.499,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE 20 MCG/HR TD PTWK",0250,A9270,00093365940,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,683.57 ,478.50 ,Aetna,"AETNA",307.61,45,percent of total billed charges,999999999,0.03087,478.499,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEGLOTICASE 8 MG/ML IV SOLN",0250,J2507,75987008010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,83562.93 ,58494.05 ,Aetna,"AETNA",6478.55,191,fee schedule,999999999,3143.5,58494.051,fee schedule,"191% of Drug Fee Schedule"
"LURASIDONE HCL 40 MG PO TABS",0250,A9270,67877063930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LURASIDONE HCL 80 MG PO TABS",0250,A9270,67877064130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTAROLINE FOSAMIL 600 MG IV SOLR",0250,J0712,00456060001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,893.56 ,625.49 ,Aetna,"AETNA",7.37,191,fee schedule,999999999,3.74,787.087,fee schedule,"191% of Drug Fee Schedule"
"CEFTAROLINE FOSAMIL 600 MG IV SOLR",0250,J0712,00456060010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1124.41 ,787.09 ,Aetna,"AETNA",7.37,191,fee schedule,999999999,3.74,787.087,fee schedule,"191% of Drug Fee Schedule"
"BETAMETHASONE VALERATE 0.1 % EX CREA",0250,A9270,00713032615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,67.10 ,46.97 ,Aetna,"AETNA",30.20,45,percent of total billed charges,999999999,0.03087,46.97,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCOPYRROLATE 1 MG/5ML PO SOLN",0250,A9270,49884004233,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,17.53 ,12.27 ,Aetna,"AETNA",7.89,45,percent of total billed charges,999999999,0.03087,12.271,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROIC ACID 250 MG/5ML PO SOLN",0250,A9270,00121467505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,10.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROIC ACID 250 MG/5ML PO SOLN",0250,A9270,00121135000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,14.35 ,10.05 ,Aetna,"AETNA",6.46,45,percent of total billed charges,999999999,0.03087,10.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROIC ACID 250 MG/5ML PO SOLN",0250,A9270,00121135010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.75 ,6.13 ,Aetna,"AETNA",3.94,45,percent of total billed charges,999999999,0.03087,10.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROIC ACID 250 MG/5ML PO SOLN",0250,A9270,00121467540,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,14.46 ,10.12 ,Aetna,"AETNA",6.51,45,percent of total billed charges,999999999,0.03087,10.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IOPAMIDOL 41 % INJ SOLN",0250,,00270141125,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,78.72 ,55.10 ,Aetna,"AETNA",35.42,45,percent of total billed charges,999999999,23.616,55.104,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 10 MG/ML IV SOLN",0250,J0131,00143938601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.046,49,fee schedule,"191% of Drug Fee Schedule"
"ACETAMINOPHEN 10 MG/ML IV SOLN",0250,J0131,00143938610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,25.20 ,17.64 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.046,49,fee schedule,"191% of Drug Fee Schedule"
"ISOSULFAN BLUE 1 % SC SOLN",0250,Q9968,67457022005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,318.39 ,222.87 ,Aetna,"AETNA",21.41,191,fee schedule,999999999,17.96,222.873,fee schedule,"191% of Drug Fee Schedule"
"ISOSULFAN BLUE 1 % SC SOLN",0250,Q9968,67457022000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,318.39 ,222.87 ,Aetna,"AETNA",21.41,191,fee schedule,999999999,17.96,222.873,fee schedule,"191% of Drug Fee Schedule"
"ISRADIPINE 5 MG PO CAPS",0250,A9270,16252054001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.02 ,9.11 ,Aetna,"AETNA",5.86,45,percent of total billed charges,999999999,0.03087,9.114,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ITRACONAZOLE 100 MG PO CAPS",0250,A9270,60687029925,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,21.75 ,15.23 ,Aetna,"AETNA",9.79,45,percent of total billed charges,999999999,0.03087,15.225,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ITRACONAZOLE 100 MG PO CAPS",0250,A9270,60687029995,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,17.30 ,12.11 ,Aetna,"AETNA",7.79,45,percent of total billed charges,999999999,0.03087,15.225,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"K PHOS MONO-SOD PHOS DI & MONO 155-852-130 MG PO TABS",0250,A9270,64980010401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETRAVIRINE 200 MG PO TABS",0250,,59676057101,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,143.18 ,100.23 ,Aetna,"AETNA",64.43,45,percent of total billed charges,999999999,42.954,100.226,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETOCONAZOLE 2 % EX CREA",0250,A9270,00168009915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,48.83 ,34.18 ,Aetna,"AETNA",21.97,45,percent of total billed charges,999999999,0.03087,34.181,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETOROLAC TROMETHAMINE 10 MG PO TABS",0250,A9270,70710171001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.14 ,4.30 ,Aetna,"AETNA",2.76,45,percent of total billed charges,999999999,0.03087,4.298,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 5 MG/ML IV SOLN",0250,J1920,25021031720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,13.72 ,9.60 ,Aetna,"AETNA",0.32,191,fee schedule,999999999,0.18,9.604,fee schedule,"191% of Drug Fee Schedule"
"LABETALOL HCL 5 MG/ML IV SOLN",0250,J1920,25021031740,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.32,191,fee schedule,999999999,0.18,9.604,fee schedule,"191% of Drug Fee Schedule"
"LABETALOL HCL 100 MG PO TABS",0250,A9270,60687043901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 100 MG PO TABS",0250,A9270,60687043911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 200 MG PO TABS",0250,A9270,60687045001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 200 MG PO TABS",0250,A9270,60687045011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 300 MG PO TABS",0250,A9270,60687046101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LABETALOL HCL 300 MG PO TABS",0250,A9270,60687046111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMMONIUM LACTATE 12 % EX LOTN",0250,A9270,45802052555,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,55.62 ,38.93 ,Aetna,"AETNA",25.03,45,percent of total billed charges,999999999,0.03087,38.934,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEUPROLIDE ACETATE 7.5 MG IM KIT",0250,J9217,00074364203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ME,,5709.78 ,3996.85 ,Aetna,"AETNA",354.61,191,fee schedule,999999999,165.86,3996.846,fee schedule,"191% of Drug Fee Schedule"
"LEVOBUNOLOL HCL 0.5 % OP SOLN",0250,A9270,24208050505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,25.62 ,17.93 ,Aetna,"AETNA",11.53,45,percent of total billed charges,999999999,0.03087,17.934,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 325 MG PR SUPP",0250,A9270,51672211602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.66 ,3.96 ,Aetna,"AETNA",2.55,45,percent of total billed charges,999999999,0.03087,3.962,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 88 MCG PO TABS",0250,A9270,00904695261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 112 MCG PO TABS",0250,A9270,00904695461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 137 MCG PO TABS",0250,A9270,60687056301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 137 MCG PO TABS",0250,A9270,60687056311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 175 MCG PO TABS",0250,A9270,00904695761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN",0250,J1652,55111068002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,157.53 ,110.27 ,Aetna,"AETNA",1.97,191,fee schedule,999999999,1.02,110.271,fee schedule,"191% of Drug Fee Schedule"
"PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP",0250,J0558,60793060010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,514.42 ,360.09 ,Aetna,"AETNA",33.18,191,fee schedule,999999999,13.17,360.094,fee schedule,"191% of Drug Fee Schedule"
"PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP",0250,J0558,60793060002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,324.40 ,227.08 ,Aetna,"AETNA",33.18,191,fee schedule,999999999,13.17,360.094,fee schedule,"191% of Drug Fee Schedule"
"PANITUMUMAB 100 MG/5ML IV SOLN",0250,J9303,55513095401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4819.74 ,3373.82 ,Aetna,"AETNA",288.87,191,fee schedule,999999999,139.67,3373.818,fee schedule,"191% of Drug Fee Schedule"
"PANITUMUMAB 400 MG/20ML IV SOLN",0250,J9303,55513095601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,19278.84 ,13495.19 ,Aetna,"AETNA",288.87,191,fee schedule,999999999,139.67,13495.188,fee schedule,"191% of Drug Fee Schedule"
"PALIVIZUMAB 50 MG/0.5ML IM SOLN",0250,90378,60574411401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5441.22 ,3808.85 ,Aetna,"AETNA",2448.55,45,percent of total billed charges,999999999,1360.305,4352.976,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PALIVIZUMAB 50 MG/0.5ML IM SOLN",0250,90378,66658023001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5441.22 ,3808.85 ,Aetna,"AETNA",2448.55,45,percent of total billed charges,999999999,1360.305,4352.976,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOCILIZUMAB 80 MG/4ML IV SOLN",0250,J3262,50242013501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",11.54,191,fee schedule,999999999,5.91,1750,fee schedule,"191% of Drug Fee Schedule"
"TOCILIZUMAB 200 MG/10ML IV SOLN",0250,J3262,50242013601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3884.13 ,2718.89 ,Aetna,"AETNA",11.54,191,fee schedule,999999999,5.91,2718.891,fee schedule,"191% of Drug Fee Schedule"
"TOCILIZUMAB 400 MG/20ML IV SOLN",0250,J3262,50242013701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,7768.26 ,5437.78 ,Aetna,"AETNA",11.54,191,fee schedule,999999999,5.91,5437.782,fee schedule,"191% of Drug Fee Schedule"
"BEVACIZUMAB 100 MG/4ML IV SOLN",0250,J9035,50242006001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",141.65,191,fee schedule,999999999,69.72,2100,fee schedule,"191% of Drug Fee Schedule"
"BEVACIZUMAB 400 MG/16ML IV SOLN",0250,J9035,50242006101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,9526.94 ,6668.86 ,Aetna,"AETNA",141.65,191,fee schedule,999999999,69.72,6668.858,fee schedule,"191% of Drug Fee Schedule"
"CETUXIMAB 200 MG/100ML IV SOLN",0250,J9055,66733095823,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4611.60 ,3228.12 ,Aetna,"AETNA",140.37,191,fee schedule,999999999,69.09,3228.12,fee schedule,"191% of Drug Fee Schedule"
"PRALATREXATE 40 MG/2ML IV SOLN",0250,J9307,48818000102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,35812.35 ,25068.65 ,Aetna,"AETNA",571.62,191,fee schedule,999999999,289.141,25068.645,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 480 MCG/1.6ML INJ SOLN",0250,J1442,55513054601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2140.01 ,1498.01 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1709.078,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 480 MCG/1.6ML INJ SOLN",0250,J1442,55513054610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2441.54 ,1709.08 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1709.078,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN",0250,J1956,00143972201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,9.10 ,6.37 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,6.37,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN",0250,J1956,00143972224,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,9.10 ,6.37 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,6.37,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN",0250,J1956,00143972101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,11.90 ,8.33 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,8.33,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN",0250,J1956,00143972124,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,11.90 ,8.33 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,8.33,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN",0250,J1956,00409052831,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,12.60 ,8.82 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,8.82,fee schedule,"191% of Drug Fee Schedule"
"LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN",0250,J1956,00409052835,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,12.60 ,8.82 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,8.82,fee schedule,"191% of Drug Fee Schedule"
"DOCETAXEL 80 MG/4ML IV CONC",0250,J9171,00955102104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,867.96 ,607.57 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,607.572,fee schedule,"191% of Drug Fee Schedule"
"DOCETAXEL 80 MG/4ML IV CONC",0250,J9171,16729026764,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,537.07 ,375.95 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,607.572,fee schedule,"191% of Drug Fee Schedule"
"DOCETAXEL 80 MG/4ML IV CONC",0250,J9171,43598025940,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,383.88 ,268.72 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,607.572,fee schedule,"191% of Drug Fee Schedule"
"NAFCILLIN SODIUM IN DEXTROSE 2 GM/100ML IV SOLN",0250,,00338101948,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,81.60 ,57.12 ,Aetna,"AETNA",36.72,45,percent of total billed charges,999999999,24.48,57.12,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIKACIN SULFATE 500 MG/2ML INJ SOLN",0250,J0278,23155029031,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,88.24 ,61.77 ,Aetna,"AETNA",1.64,191,fee schedule,999999999,0.829,61.768,fee schedule,"191% of Drug Fee Schedule"
"AMIKACIN SULFATE 500 MG/2ML INJ SOLN",0250,J0278,23155029041,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,32.12 ,22.48 ,Aetna,"AETNA",1.64,191,fee schedule,999999999,0.829,61.768,fee schedule,"191% of Drug Fee Schedule"
"CLINDAMYCIN PHOSPHATE 9 GM/60ML INJ SOLN",0250,J0736,63323028260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,72.00 ,50.40 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,50.4,fee schedule,"191% of Drug Fee Schedule"
"IRINOTECAN HCL 300 MG/15ML IV SOLN",0250,J9206,00009752905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,375.21 ,262.65 ,Aetna,"AETNA",6.70,191,fee schedule,999999999,1.945,262.647,fee schedule,"191% of Drug Fee Schedule"
"BACLOFEN 10 MG/20ML IT SOLN",0250,J0475,70257056001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,900.00 ,630.00 ,Aetna,"AETNA",339.73,191,fee schedule,999999999,177.804,630,fee schedule,"191% of Drug Fee Schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,00409317801,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,15.54 ,10.88 ,Aetna,"AETNA",6.99,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,63323048257,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,65.45 ,45.82 ,Aetna,"AETNA",29.45,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,63323048217,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,22.61 ,15.83 ,Aetna,"AETNA",10.17,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,99999033899,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,39.27 ,27.49 ,Aetna,"AETNA",17.67,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,63323048201,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,22.61 ,15.83 ,Aetna,"AETNA",10.17,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLN",0250,,00409317816,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,14.56 ,10.19 ,Aetna,"AETNA",6.55,45,percent of total billed charges,999999999,4.368,45.815,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:200000 INJ SOLN",0250,,63323048737,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,16.611,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:200000 INJ SOLN",0250,,63323048717,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,55.37 ,38.76 ,Aetna,"AETNA",24.92,45,percent of total billed charges,999999999,16.611,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1 %-1:200000 INJ SOLN",0250,,63323048707,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,16.611,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 INJ SOLN",0250,,63323048831,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,56.49 ,39.54 ,Aetna,"AETNA",25.42,45,percent of total billed charges,999999999,16.947,39.543,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BETHANECHOL CHLORIDE 10 MG PO TABS",0250,A9270,00832051101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BETHANECHOL CHLORIDE 10 MG PO TABS",0250,A9270,00832051189,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 INJ SOLN",0250,,00409318202,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,33.60 ,23.52 ,Aetna,"AETNA",15.12,45,percent of total billed charges,999999999,8.526,23.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 INJ SOLN",0250,,63323048327,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,28.42 ,19.89 ,Aetna,"AETNA",12.79,45,percent of total billed charges,999999999,8.526,23.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 INJ SOLN",0250,,63323048303,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,28.42 ,19.89 ,Aetna,"AETNA",12.79,45,percent of total billed charges,999999999,8.526,23.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:100000 INJ SOLN",0250,,00409318221,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,31.29 ,21.90 ,Aetna,"AETNA",14.08,45,percent of total billed charges,999999999,8.526,23.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:200000 INJ SOLN",0250,,00409318301,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,32.62 ,22.83 ,Aetna,"AETNA",14.68,45,percent of total billed charges,999999999,9.786,46.844,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:200000 INJ SOLN",0250,,63323048917,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,66.92 ,46.84 ,Aetna,"AETNA",30.11,45,percent of total billed charges,999999999,9.786,46.844,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:200000 INJ SOLN",0250,,63323048901,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,66.92 ,46.84 ,Aetna,"AETNA",30.11,45,percent of total billed charges,999999999,9.786,46.844,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-EPINEPHRINE 2 %-1:200000 INJ SOLN",0250,,00409318311,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,32.62 ,22.83 ,Aetna,"AETNA",14.68,45,percent of total billed charges,999999999,9.786,46.844,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA",0250,,00168035755,RC,,NDC,FACILITY,OUTPATIENT,5,GR,,58.49 ,40.94 ,Aetna,"AETNA",26.32,45,percent of total billed charges,999999999,6.063,40.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA",0250,,81033002501,RC,,NDC,FACILITY,OUTPATIENT,5,GR,,20.21 ,14.15 ,Aetna,"AETNA",9.09,45,percent of total billed charges,999999999,6.063,40.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA",0250,,81033002550,RC,,NDC,FACILITY,OUTPATIENT,5,GR,,20.21 ,14.15 ,Aetna,"AETNA",9.09,45,percent of total billed charges,999999999,6.063,40.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RUFINAMIDE 40 MG/ML PO SUSP",0250,A9270,67877067362,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,90.93 ,63.65 ,Aetna,"AETNA",40.92,45,percent of total billed charges,999999999,0.03087,63.651,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BELIMUMAB 120 MG IV SOLR",0250,J0490,49401010101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",103.33,191,fee schedule,999999999,49.47,1750,fee schedule,"191% of Drug Fee Schedule"
"BELIMUMAB 400 MG IV SOLR",0250,J0490,49401010201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,6107.40 ,4275.18 ,Aetna,"AETNA",103.33,191,fee schedule,999999999,49.47,4275.18,fee schedule,"191% of Drug Fee Schedule"
"BETHANECHOL CHLORIDE 25 MG PO TABS",0250,A9270,00832051201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BETHANECHOL CHLORIDE 25 MG PO TABS",0250,A9270,00832051289,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIOTHYRONINE SODIUM 5 MCG PO TABS",0250,A9270,70377011412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LISINOPRIL 10 MG PO TABS",0250,A9270,00904679861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IPILIMUMAB 50 MG/10ML IV SOLN",0250,J9228,00003232711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,25500.21 ,17850.15 ,Aetna,"AETNA",329.88,191,fee schedule,999999999,163.1,17850.147,fee schedule,"191% of Drug Fee Schedule"
"IPILIMUMAB 200 MG/40ML IV SOLN",0250,J9228,00003232822,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,102000.60 ,71400.42 ,Aetna,"AETNA",329.88,191,fee schedule,999999999,163.1,71400.42,fee schedule,"191% of Drug Fee Schedule"
"LISINOPRIL 5 MG PO TABS",0250,A9270,00904679761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LITHIUM CARBONATE ER 300 MG PO TBCR",0250,A9270,68084064001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LITHIUM CARBONATE ER 300 MG PO TBCR",0250,A9270,68084064011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LITHIUM CARBONATE ER 450 MG PO TBCR",0250,A9270,68084065501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LITHIUM CARBONATE ER 450 MG PO TBCR",0250,A9270,68084065511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOMUSTINE 40 MG PO CAPS",0250,A9270,00015303120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.74 ,11.72 ,Aetna,"AETNA",7.53,45,percent of total billed charges,999999999,0.03087,11.718,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORATADINE 10 MG PO TABS",0250,A9270,50268048911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORATADINE 10 MG PO TABS",0250,A9270,50268048915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00409198530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,22.88 ,16.02 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00641604401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00641604425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00641604601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00641604610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 2 MG/ML INJ SOLN",0250,J2060,00409198503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,21.57 ,15.10 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,16.016,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 4 MG/ML INJ SOLN",0250,J2060,00641604701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,3.5,fee schedule,"191% of Drug Fee Schedule"
"LORAZEPAM 4 MG/ML INJ SOLN",0250,J2060,00641604710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,3.5,fee schedule,"191% of Drug Fee Schedule"
"LOVASTATIN 20 MG PO TABS",0250,A9270,68180046801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV INJ",0250,J7504,00009722402,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,10643.76 ,7450.63 ,Aetna,"AETNA",6904.27,191,fee schedule,999999999,2782.17,7450.632,fee schedule,"191% of Drug Fee Schedule"
"MAFENIDE ACETATE 85 MG/GM EX CREA",0250,,16571072360,RC,,NDC,FACILITY,OUTPATIENT,56.7,GR,,404.50 ,283.15 ,Aetna,"AETNA",182.03,45,percent of total billed charges,999999999,121.35,283.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D3 125 MCG (5000 UT) PO TABS",0250,A9270,50268086611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D3 125 MCG (5000 UT) PO TABS",0250,A9270,50268086615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 650 MG PR SUPP",0250,A9270,45802073032,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VILAZODONE HCL 20 MG PO TABS",0250,A9270,62332023330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.97 ,6.28 ,Aetna,"AETNA",4.04,45,percent of total billed charges,999999999,0.03087,6.279,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VILAZODONE HCL 40 MG PO TABS",0250,A9270,62332023430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.60 ,5.32 ,Aetna,"AETNA",3.42,45,percent of total billed charges,999999999,0.03087,5.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEDIUM CHAIN TRIGLYCERIDES PO OIL",0250,A9270,41679036513,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,14.28 ,10.00 ,Aetna,"AETNA",6.43,45,percent of total billed charges,999999999,0.03087,9.996,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEGESTROL ACETATE 40 MG/ML PO SUSP",0250,,64380016001,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7.38 ,5.17 ,Aetna,"AETNA",3.32,45,percent of total billed charges,999999999,2.214,5.166,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MERCAPTOPURINE 50 MG PO TABS",0250,A9270,00054458111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.75 ,4.03 ,Aetna,"AETNA",2.59,45,percent of total billed charges,999999999,0.03087,4.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MESALAMINE ER 250 MG PO CPCR",0250,A9270,54092018981,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,19.79 ,13.85 ,Aetna,"AETNA",8.91,45,percent of total billed charges,999999999,0.03087,13.853,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MESALAMINE 4 G PR ENEM",0250,A9270,45802009851,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,49.56 ,34.69 ,Aetna,"AETNA",22.30,45,percent of total billed charges,999999999,0.03087,34.692,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MESNA 100 MG/ML IV SOLN",0250,J9209,63323073310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,332.34 ,232.64 ,Aetna,"AETNA",3.36,191,fee schedule,999999999,1.372,232.638,fee schedule,"191% of Drug Fee Schedule"
"RILPIVIRINE HCL 25 MG PO TABS",0250,A9270,59676027801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,263.29 ,184.30 ,Aetna,"AETNA",118.48,45,percent of total billed charges,999999999,0.03087,184.303,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METAXALONE 400 MG PO TABS",0250,A9270,00115174501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,32.38 ,22.67 ,Aetna,"AETNA",14.57,45,percent of total billed charges,999999999,0.03087,22.666,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METFORMIN HCL 500 MG PO TABS",0250,A9270,00904716261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 10 MG/ML INJ SOLN",0250,J1230,67457021720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,24.88 ,17.42 ,Aetna,"AETNA",39.37,191,fee schedule,999999999,7.464,60.704,fee schedule,"191% of Drug Fee Schedule"
"METHADONE HCL 10 MG/ML INJ SOLN",0250,J1230,99999030499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,86.72 ,60.70 ,Aetna,"AETNA",39.37,191,fee schedule,999999999,7.464,60.704,fee schedule,"191% of Drug Fee Schedule"
"METHENAMINE HIPPURATE 1 G PO TABS",0250,A9270,65862078201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.50 ,3.85 ,Aetna,"AETNA",2.48,45,percent of total billed charges,999999999,0.03087,3.85,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHIMAZOLE 10 MG PO TABS",0250,A9270,23155007101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHIMAZOLE 5 MG PO TABS",0250,A9270,60687066901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHIMAZOLE 5 MG PO TABS",0250,A9270,60687066911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TPN ELECTROLYTES IV CONC",0250,,00409577901,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,64.12 ,44.88 ,Aetna,"AETNA",28.85,45,percent of total billed charges,999999999,19.236,44.884,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN 10 MG PO TABS",0250,A9270,50458058010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN",0250,J0283,43066015010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,118.80 ,83.16 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.76,83.16,fee schedule,"191% of Drug Fee Schedule"
"AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN",0250,J0283,43066036020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,136.80 ,95.76 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.76,95.76,fee schedule,"191% of Drug Fee Schedule"
"METHYLERGONOVINE MALEATE 0.2 MG/ML INJ SOLN",0250,J2210,00517074020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.2,ME,,115.32 ,80.72 ,Aetna,"AETNA",39.86,191,fee schedule,999999999,19.603,80.724,fee schedule,"191% of Drug Fee Schedule"
"METHYLERGONOVINE MALEATE 0.2 MG/ML INJ SOLN",0250,J2210,00517074001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.2,ME,,115.32 ,80.72 ,Aetna,"AETNA",39.86,191,fee schedule,999999999,19.603,80.724,fee schedule,"191% of Drug Fee Schedule"
"METHYLERGONOVINE MALEATE 0.2 MG PO TABS",0250,A9270,69238160502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,168.64 ,118.05 ,Aetna,"AETNA",75.89,45,percent of total billed charges,999999999,0.03087,118.048,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TICAGRELOR 90 MG PO TABS",0250,A9270,00186077739,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,48.77 ,34.14 ,Aetna,"AETNA",21.95,45,percent of total billed charges,999999999,0.03087,34.139,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLPREDNISOLONE SODIUM SUCC 2000 MG INJ SOLR",0250,J2919,00009079601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,459.24 ,321.47 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,321.468,fee schedule,"191% of Drug Fee Schedule"
"METOLAZONE 2.5 MG PO TABS",0250,A9270,00185505001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOLAZONE 5 MG PO TABS",0250,A9270,00185005501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE 0.75 % VA GEL",0250,A9270,73473030370,RC,HCPCS,NDC,FACILITY,OUTPATIENT,70,GR,,262.92 ,184.04 ,Aetna,"AETNA",118.31,45,percent of total billed charges,999999999,0.03087,184.044,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEXILETINE HCL 150 MG PO CAPS",0250,A9270,50742023901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEXILETINE HCL 250 MG PO CAPS",0250,A9270,50742024101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.22 ,5.05 ,Aetna,"AETNA",3.25,45,percent of total billed charges,999999999,0.03087,5.054,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BELATACEPT 250 MG IV SOLR",0250,J0485,00003037113,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",7.39,191,fee schedule,999999999,3.78,2100,fee schedule,"191% of Drug Fee Schedule"
"MICONAZOLE NITRATE 100 MG VA SUPP",0250,A9270,61269073607,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7,UN  ,,6.83 ,4.78 ,Aetna,"AETNA",3.07,45,percent of total billed charges,999999999,0.03087,4.781,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT",0250,J9217,00074347303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ME,,34259.13 ,23981.39 ,Aetna,"AETNA",354.61,191,fee schedule,999999999,165.86,23981.391,fee schedule,"191% of Drug Fee Schedule"
"MIDODRINE HCL 2.5 MG PO TABS",0250,A9270,00904681761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.19 ,3.63 ,Aetna,"AETNA",2.34,45,percent of total billed charges,999999999,0.03087,3.633,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIDODRINE HCL 5 MG PO TABS",0250,A9270,63739014510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOCYCLINE HCL 100 MG IV SOLR",0250,J2265,70842016001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1112.67 ,778.87 ,Aetna,"AETNA",5.75,191,fee schedule,999999999,2.39,817.649,fee schedule,"191% of Drug Fee Schedule"
"MINOCYCLINE HCL 100 MG IV SOLR",0250,J2265,70842016010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1168.07 ,817.65 ,Aetna,"AETNA",5.75,191,fee schedule,999999999,2.39,817.649,fee schedule,"191% of Drug Fee Schedule"
"MISOPROSTOL 100 MCG PO TABS",0250,A9270,70954044310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MISOPROSTOL 200 MCG PO TABS",0250,A9270,70954044420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MITOMYCIN 20 MG IV SOLR",0250,J9280,00143927901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,900.00 ,630.00 ,Aetna,"AETNA",128.03,191,fee schedule,999999999,54.29,630,fee schedule,"191% of Drug Fee Schedule"
"MITOMYCIN 5 MG IV SOLR",0250,J9280,16729011505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,302.52 ,211.76 ,Aetna,"AETNA",128.03,191,fee schedule,999999999,54.29,211.764,fee schedule,"191% of Drug Fee Schedule"
"OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR",0250,A9270,68180067801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.27 ,8.59 ,Aetna,"AETNA",5.52,45,percent of total billed charges,999999999,0.03087,8.589,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOMETASONE FUROATE 0.1 % EX CREA",0250,A9270,00713063415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,27.83 ,19.48 ,Aetna,"AETNA",12.52,45,percent of total billed charges,999999999,0.03087,19.481,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOMETASONE FUROATE 0.1 % EX OINT",0250,A9270,45802011937,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,32.97 ,23.08 ,Aetna,"AETNA",14.84,45,percent of total billed charges,999999999,0.03087,23.079,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PANCRELIPASE (LIP-PROT-AMYL) 3000-9500 UNITS PO CPEP",0250,A9270,00032120370,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,11.44 ,8.01 ,Aetna,"AETNA",5.15,45,percent of total billed charges,999999999,0.03087,8.008,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN",0250,A9270,99999251999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE (CONCENTRATE) 20 MG/ML PO SOLN",0250,A9270,00054051744,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRENTUXIMAB VEDOTIN 50 MG IV SOLR",0250,J9042,51144005001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,33906.00 ,23734.20 ,Aetna,"AETNA",440.71,191,fee schedule,999999999,205.76,23734.2,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 1 GM/10ML INJ SOLN",0250,J1569,00944270002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,411.12 ,287.78 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,287.784,fee schedule,"191% of Drug Fee Schedule"
"MUPIROCIN 2 % EX OINT",0250,,51672131200,RC,,NDC,FACILITY,OUTPATIENT,22,GR,,31.57 ,22.10 ,Aetna,"AETNA",14.21,45,percent of total billed charges,999999999,9.471,22.099,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GAMMAGARD 2.5 GM/25ML INJ SOLN",0250,J1569,00944270003,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,900.00 ,630.00 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,630,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 5 GM/50ML INJ SOLN",0250,J1569,00944270004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,1713.00 ,1199.10 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,1199.1,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 10 GM/100ML INJ SOLN",0250,J1569,00944270005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,2740.80 ,1918.56 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,1918.56,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 10 GM/100ML INJ SOLN",0250,J1569,00944270011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,2740.80 ,1918.56 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,1918.56,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 20 GM/200ML INJ SOLN",0250,J1569,00944270006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,4111.20 ,2877.84 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,2877.84,fee schedule,"191% of Drug Fee Schedule"
"GAMMAGARD 30 GM/300ML INJ SOLN",0250,J1569,00944270007,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,6166.80 ,4316.76 ,Aetna,"AETNA",82.55,191,fee schedule,999999999,44.152,4316.76,fee schedule,"191% of Drug Fee Schedule"
"NABUMETONE 500 MG PO TABS",0250,A9270,69097096507,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NABUMETONE 750 MG PO TABS",0250,A9270,00185014601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.96 ,4.17 ,Aetna,"AETNA",2.68,45,percent of total billed charges,999999999,0.03087,4.172,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAFCILLIN SODIUM IN DEXTROSE 1 GM/50ML IV SOLN",0250,,00338101741,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,56.00 ,39.20 ,Aetna,"AETNA",25.20,45,percent of total billed charges,999999999,16.8,39.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NALTREXONE HCL 50 MG PO TABS",0250,A9270,00904703604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.91 ,7.64 ,Aetna,"AETNA",4.91,45,percent of total billed charges,999999999,0.03087,7.637,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAPROXEN 125 MG/5ML PO SUSP",0250,A9270,69238173002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,1340.96 ,938.67 ,Aetna,"AETNA",603.43,45,percent of total billed charges,999999999,0.03087,938.672,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN-POLYMYXIN B GU IR SOLN",0250,,39822120105,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE POLACRILEX 2 MG MT GUM",0250,A9270,00536302934,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE POLACRILEX 2 MG MT GUM",0250,A9270,70000034801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIMODIPINE 30 MG PO CAPS",0250,A9270,23155051200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.41 ,4.49 ,Aetna,"AETNA",2.88,45,percent of total billed charges,999999999,0.03087,4.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROFURANTOIN 25 MG/5ML PO SUSP",0250,A9270,59630045008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,146.10 ,102.27 ,Aetna,"AETNA",65.75,45,percent of total billed charges,999999999,0.03087,102.27,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS",0250,A9270,65162047810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBANDRONATE SODIUM 3 MG/3ML IV SOLN",0250,J1740,25021082761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,481.36 ,336.95 ,Aetna,"AETNA",60.57,191,fee schedule,999999999,24.9,336.952,fee schedule,"191% of Drug Fee Schedule"
"OXYCODONE-ASPIRIN 4.8355-325 MG PO TABS",0250,A9270,00378611701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXOCOBALAMIN 5 G IV SOLR",0250,J3425,50633031011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,mcg,,3000.00 ,2100.00 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.005,2100,fee schedule,"191% of Drug Fee Schedule"
"ZOLEDRONIC ACID 4 MG/100ML IV SOLN",0250,J3489,00078059061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",13.26,191,fee schedule,999999999,6.93,2100,fee schedule,"191% of Drug Fee Schedule"
"ZOLEDRONIC ACID 4 MG/100ML IV SOLN",0250,J3489,25021082682,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,246.00 ,172.20 ,Aetna,"AETNA",13.26,191,fee schedule,999999999,6.93,2100,fee schedule,"191% of Drug Fee Schedule"
"NORETHINDRONE ACETATE 5 MG PO TABS",0250,A9270,68462030450,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORGESTREL-ETHINYL ESTRADIOL 0.3-30 MG-MCG PO TABS",0250,A9270,00555904979,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NUTRISOURCE FIBER PO PACK",0250,,43900097647,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST VHC PO LIQD",0250,,43900018215,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,7.58 ,5.31 ,Aetna,"AETNA",3.41,45,percent of total billed charges,999999999,2.274,5.306,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BISACODYL 10 MG PR SUPP",0250,A9270,00574705050,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXANDROLONE 2.5 MG PO TABS",0250,A9270,49884030101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.10 ,10.57 ,Aetna,"AETNA",6.80,45,percent of total billed charges,999999999,0.03087,10.57,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCHLOROSENE SODIUM POWD",0250,,00327000110,RC,,NDC,FACILITY,OUTPATIENT,2,GR,,50.96 ,35.67 ,Aetna,"AETNA",22.93,45,percent of total billed charges,999999999,15.288,35.672,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 100 MG/5ML PO CONC",0250,A9270,99999015599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,22.86 ,16.00 ,Aetna,"AETNA",10.29,45,percent of total billed charges,999999999,0.03087,16.002,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 100 MG/5ML PO CONC",0250,A9270,71930002330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,16.002,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 5 MG/5ML PO SOLN",0250,A9270,64950035405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,50.40 ,35.28 ,Aetna,"AETNA",22.68,45,percent of total billed charges,999999999,0.03087,35.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 5 MG/5ML PO SOLN",0250,A9270,64950035455,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,16.94 ,11.86 ,Aetna,"AETNA",7.62,45,percent of total billed charges,999999999,0.03087,35.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 5 MG/5ML PO SOLN",0250,A9270,99999019899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,6.96 ,4.87 ,Aetna,"AETNA",3.13,45,percent of total billed charges,999999999,0.03087,35.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 5 MG/5ML PO SOLN",0250,A9270,00904667840,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,35.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOBAZAM 10 MG PO TABS",0250,A9270,67386031401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,166.57 ,116.60 ,Aetna,"AETNA",74.96,45,percent of total billed charges,999999999,0.03087,116.599,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 5 MG PO TABS",0250,A9270,00904696661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE LIPOSOME 1.3 % INJ SUSP",0250,C9290,65250026609,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1880.60 ,1316.42 ,Aetna,"AETNA",3.25,191,fee schedule,999999999,1.33,1316.42,fee schedule,"191% of Drug Fee Schedule"
"GEMCITABINE HCL 200 MG/5.26ML IV SOLN",0250,J9201,00409018301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,32.33 ,22.63 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,3.651,22.631,fee schedule,"191% of Drug Fee Schedule"
"GEMCITABINE HCL 1 GM/26.3ML IV SOLN",0250,J9201,00409018101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,90.42 ,63.29 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,3.651,63.294,fee schedule,"191% of Drug Fee Schedule"
"GEMCITABINE HCL 2 GM/52.6ML IV SOLN",0250,J9201,00409018201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,170.42 ,119.29 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,3.651,119.294,fee schedule,"191% of Drug Fee Schedule"
"IMPACT PEPTIDE 1.5 PO LIQD",0250,,43900097370,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,222.00 ,155.40 ,Aetna,"AETNA",99.90,45,percent of total billed charges,999999999,66.6,155.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN 15 MG PO TABS",0250,A9270,50458057810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN 15 MG PO TABS",0250,A9270,50458057801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN 20 MG PO TABS",0250,A9270,50458057910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR",0250,,43386009019,RC,,NDC,FACILITY,OUTPATIENT,4000,ML,,96.00 ,67.20 ,Aetna,"AETNA",43.20,45,percent of total billed charges,999999999,28.8,67.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 100 MCG IV SOLR",0250,,42023020101,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,374.28 ,262.00 ,Aetna,"AETNA",168.43,45,percent of total billed charges,999999999,112.284,261.996,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAROXETINE HCL 20 MG PO TABS",0250,A9270,00904567761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAROXETINE HCL 30 MG PO TABS",0250,A9270,13107015630,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP",0250,A9270,00536128636,RC,HCPCS,NDC,FACILITY,OUTPATIENT,240,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOSTATIN 10 MG IV SOLR",0250,J9268,00409080101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,7325.28 ,5127.70 ,Aetna,"AETNA",4461.23,191,fee schedule,999999999,2197.584,5127.696,fee schedule,"191% of Drug Fee Schedule"
"PERMETHRIN 5 % EX CREA",0250,A9270,21922002107,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,GR,,103.68 ,72.58 ,Aetna,"AETNA",46.66,45,percent of total billed charges,999999999,0.03087,72.576,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PERMETHRIN 1 % EX LIQD",0250,A9270,70000004101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,59,ML,,50.39 ,35.27 ,Aetna,"AETNA",22.68,45,percent of total billed charges,999999999,12.5975,35.273,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN",0250,J1953,43598063510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,111.00 ,77.70 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,77.7,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN",0250,J1953,43598063552,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,111.00 ,77.70 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,77.7,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN",0250,J1953,67457026500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,49,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN",0250,J1953,67457026510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,49,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN",0250,J1953,67457026600,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,87.00 ,60.90 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,168,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN",0250,J1953,67457026610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,87.00 ,60.90 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,168,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN",0250,J1953,43598063710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,240.00 ,168.00 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,168,fee schedule,"191% of Drug Fee Schedule"
"LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN",0250,J1953,43598063752,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,240.00 ,168.00 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,168,fee schedule,"191% of Drug Fee Schedule"
"NITROGLYCERIN 0.4 % PR OINT",0250,A9270,99999061699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,338.94 ,237.26 ,Aetna,"AETNA",152.52,45,percent of total billed charges,999999999,0.03087,237.258,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LURASIDONE HCL 20 MG PO TABS",0250,A9270,67877063830,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENELZINE SULFATE 15 MG PO TABS",0250,A9270,00071035060,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.63 ,11.64 ,Aetna,"AETNA",7.48,45,percent of total billed charges,999999999,0.03087,11.641,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLNALTREXONE BROMIDE 8 MG/0.4ML SC SOLN",0250,J2212,65649055204,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,859.48 ,601.64 ,Aetna,"AETNA",3.06,191,fee schedule,999999999,1.28,601.636,fee schedule,"191% of Drug Fee Schedule"
"PHENTOLAMINE MESYLATE 5 MG INJ SOLR",0250,J2760,51224001220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1641.05 ,1148.74 ,Aetna,"AETNA",848.65,191,fee schedule,999999999,413.47,1148.735,fee schedule,"191% of Drug Fee Schedule"
"PHENYTOIN 50 MG PO CHEW",0250,A9270,60687015625,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYTOIN 50 MG PO CHEW",0250,A9270,60687015695,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RACEPINEPHRINE HCL 2.25 % INH NEBU",0250,A9270,00487590199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.88 ,6.92 ,Aetna,"AETNA",4.45,45,percent of total billed charges,999999999,0.03087,6.916,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RACEPINEPHRINE HCL 2.25 % INH NEBU",0250,A9270,0543071012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.27 ,4.39 ,Aetna,"AETNA",2.82,45,percent of total billed charges,999999999,0.03087,6.916,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RACEPINEPHRINE HCL 2.25 % INH NEBU",0250,A9270,00487278401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.27 ,4.39 ,Aetna,"AETNA",2.82,45,percent of total billed charges,999999999,0.03087,6.916,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHYTONADIONE 10 MG/ML INJ SOLN",0250,,43598040516,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,127.37 ,89.16 ,Aetna,"AETNA",57.32,45,percent of total billed charges,999999999,38.211,89.159,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHYTONADIONE 5 MG PO TABS",0250,A9270,69238105103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,101.88 ,71.32 ,Aetna,"AETNA",45.85,45,percent of total billed charges,999999999,0.03087,71.316,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOPERAMIDE HCL 1 MG/7.5ML PO SUSP",0250,A9270,00904683620,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML INJ INJ",0250,90732,00006483703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,126.00 ,88.20 ,Aetna,"AETNA",56.70,45,percent of total billed charges,999999999,31.5,88.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML INJ INJ",0250,90732,00006483701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,126.00 ,88.20 ,Aetna,"AETNA",56.70,45,percent of total billed charges,999999999,31.5,88.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM POLYCARBOPHIL 625 MG PO TABS",0250,A9270,00005250033,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN",0250,J3480,00338070948,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,20.30 ,14.21 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.7,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN",0250,J3480,99999024399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,21.00 ,14.70 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.7,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN",0250,J3480,00338070548,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,21.00 ,14.70 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.7,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN",0250,J3480,00990707526,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,19.60 ,13.72 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.7,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE 40 MEQ/100ML IV SOLN",0250,J3480,00338070348,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,20.30 ,14.21 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.21,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN",0250,,00338069104,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN",0250,,99999056899,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN",0250,,00338069504,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR",0250,A9270,42543040701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CITRATE ER 5 MEQ (540 MG) PO TBCR",0250,A9270,00245007011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 10 MG PO TABS",0250,A9270,60687016901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 10 MG PO TABS",0250,A9270,60687016911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 20 MG PO TABS",0250,A9270,00093720198,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 20 MG PO TABS",0250,A9270,51079045801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 20 MG PO TABS",0250,A9270,68462019690,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 20 MG PO TABS",0250,A9270,68382007116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAVASTATIN SODIUM 20 MG PO TABS",0250,A9270,60687017811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAZIQUANTEL 600 MG PO TABS",0250,A9270,49884023183,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,342.91 ,240.04 ,Aetna,"AETNA",154.31,45,percent of total billed charges,999999999,0.03087,240.037,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRIMIDONE 50 MG PO TABS",0250,A9270,53746054401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROCHLORPERAZINE 25 MG PR SUPP",0250,A9270,00574722612,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,28.97 ,20.28 ,Aetna,"AETNA",13.04,45,percent of total billed charges,999999999,0.03087,20.279,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 12.5 MG PR SUPP",0250,A9270,00713053612,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",15.40,45,percent of total billed charges,999999999,0.03087,23.961,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 12.5 MG PR SUPP",0250,A9270,00713053606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",15.40,45,percent of total billed charges,999999999,0.03087,23.961,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 25 MG PR SUPP",0250,A9270,00713052606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.15 ,9.91 ,Aetna,"AETNA",6.37,45,percent of total billed charges,999999999,0.03087,19.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 25 MG PR SUPP",0250,A9270,00713052612,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,28.30 ,19.81 ,Aetna,"AETNA",12.74,45,percent of total billed charges,999999999,0.03087,19.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPAFENONE HCL 150 MG PO TABS",0250,A9270,59651025601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPOFOL 10 MG/ML IV EMUL",0250,J2704,63323026965,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.1,49,fee schedule,"191% of Drug Fee Schedule"
"PROPOFOL 10 MG/ML IV EMUL",0250,J2704,63323026950,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.42 ,10.09 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.1,49,fee schedule,"191% of Drug Fee Schedule"
"PROPOFOL 10 MG/ML IV EMUL",0250,J2704,63323026929,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.42 ,10.09 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.1,49,fee schedule,"191% of Drug Fee Schedule"
"PERTUZUMAB 420 MG/14ML IV SOLN",0250,J9306,50242014501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,19505.93 ,13654.15 ,Aetna,"AETNA",29.45,191,fee schedule,999999999,14.44,13654.151,fee schedule,"191% of Drug Fee Schedule"
"ACETAZOLAMIDE 125 MG PO TABS",0250,A9270,23155028701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CULTURELLE PO CAPS",0250,A9270,49100040007,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOCETAXEL 160 MG/8ML IV CONC",0250,J9171,67457078108,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,900.00 ,630.00 ,Aetna,"AETNA",1.66,191,fee schedule,999999999,0.47,630,fee schedule,"191% of Drug Fee Schedule"
"CARFILZOMIB 60 MG IV SOLR",0250,J9047,76075010101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9347.88 ,6543.52 ,Aetna,"AETNA",90.11,191,fee schedule,999999999,44.03,6543.516,fee schedule,"191% of Drug Fee Schedule"
"PYRIDOSTIGMINE BROMIDE 60 MG PO TABS",0250,A9270,00904662261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR",0250,A9270,47781033530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,43.32 ,30.32 ,Aetna,"AETNA",19.49,45,percent of total billed charges,999999999,0.03087,30.324,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIMETHAMINE 25 MG PO TABS",0250,A9270,52054033010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.79 ,53.75 ,Aetna,"AETNA",34.56,45,percent of total billed charges,999999999,0.03087,53.753,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RAMIPRIL 2.5 MG PO CAPS",0250,A9270,65862047501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RAMIPRIL 5 MG PO CAPS",0250,A9270,65862047601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIBAVIRIN 200 MG PO CAPS",0250,A9270,65862029084,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.59 ,11.61 ,Aetna,"AETNA",7.47,45,percent of total billed charges,999999999,0.03087,11.613,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIFABUTIN 150 MG PO CAPS",0250,A9270,00013530117,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,53.21 ,37.25 ,Aetna,"AETNA",23.94,45,percent of total billed charges,999999999,0.03087,37.247,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIFAMPIN 600 MG IV SOLR",0250,J3490,63323035120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,600,ME,,416.10 ,291.27 ,Aetna,"AETNA",187.25,45,percent of total billed charges,999999999,124.83,291.27,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RALTEGRAVIR POTASSIUM 25 MG PO CHEW",0250,A9270,00006047361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,217.28 ,152.10 ,Aetna,"AETNA",97.78,45,percent of total billed charges,999999999,0.03087,152.096,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML INJ SOLN",0250,J1100,63323050601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9.52 ,6.66 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,6.664,fee schedule,"191% of Drug Fee Schedule"
"RIFAMPIN 300 MG PO CAPS",0250,A9270,68180065906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROMORPHONE HCL PF 1 MG/ML INJ SOLN",0250,J1170,63323085203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,20.08 ,14.06 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,14.056,fee schedule,"191% of Drug Fee Schedule"
"HYDROMORPHONE HCL PF 1 MG/ML INJ SOLN",0250,J1170,63323085225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,20.08 ,14.06 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,14.056,fee schedule,"191% of Drug Fee Schedule"
"HYDROMORPHONE HCL PF 10 MG/ML INJ SOLN",0250,J1170,00409263405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,70.00 ,49.00 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,347.55,fee schedule,"191% of Drug Fee Schedule"
"HYDROMORPHONE HCL PF 10 MG/ML INJ SOLN",0250,J1170,00703001801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,496.50 ,347.55 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,347.55,fee schedule,"191% of Drug Fee Schedule"
"HYDROMORPHONE HCL PF 10 MG/ML INJ SOLN",0250,J1170,00409263425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,61.25 ,42.88 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,347.55,fee schedule,"191% of Drug Fee Schedule"
"ACETAZOLAMIDE 250 MG PO TABS",0250,A9270,72578015001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SELEGILINE HCL 5 MG PO TABS",0250,A9270,00378929091,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,20.73 ,14.51 ,Aetna,"AETNA",9.33,45,percent of total billed charges,999999999,0.03087,14.511,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORMAL SALINE FLUSH 0.9 % IV SOLN",0250,,08881570300,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,6.00 ,4.20 ,Aetna,"AETNA",2.70,45,percent of total billed charges,999999999,1.5,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORMAL SALINE FLUSH 0.9 % IV SOLN",0250,,08290306500,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MAGNESIUM OXIDE -MG SUPPLEMENT 400 (240 MG) MG PO TABS",0250,A9270,60258017101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SENNOSIDES 8.6 MG PO TABS",0250,A9270,00904725261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SERTRALINE HCL 100 MG PO TABS",0250,A9270,00904692661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SERTRALINE HCL 50 MG PO TABS",0250,A9270,00904692561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SILVER NITRATE-POT NITRATE 75-25 % EX MISC",0250,,12165010001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMVASTATIN 10 MG PO TABS",0250,A9270,63739057110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMVASTATIN 20 MG PO TABS",0250,A9270,63739057210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMVASTATIN 40 MG PO TABS",0250,A9270,63739057310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMVASTATIN 5 MG PO TABS",0250,A9270,63739057010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SINCALIDE 5 MCG INJ SOLR",0250,J2805,63323057901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,mcg,,386.32 ,270.42 ,Aetna,"AETNA",247.80,191,fee schedule,999999999,115.896,270.424,fee schedule,"191% of Drug Fee Schedule"
"SINCALIDE 5 MCG INJ SOLR",0250,J2805,63323057905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,mcg,,386.32 ,270.42 ,Aetna,"AETNA",247.80,191,fee schedule,999999999,115.896,270.424,fee schedule,"191% of Drug Fee Schedule"
"SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN",0250,A9270,00904731662,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.33 ,10.73 ,Aetna,"AETNA",6.90,45,percent of total billed charges,999999999,0.03087,10.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN",0250,A9270,00904731673,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.33 ,10.73 ,Aetna,"AETNA",6.90,45,percent of total billed charges,999999999,0.03087,10.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAZOLAMIDE SODIUM 500 MG INJ SOLR",0250,J1120,39822019001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,35.00 ,24.50 ,Aetna,"AETNA",50.10,191,fee schedule,999999999,10.5,50.0993,fee schedule,"191% of Drug Fee Schedule"
"SODIUM CHLORIDE 0.9 % IR SOLN",0250,,00338004804,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9 % IR SOLN",0250,,00990797208,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,4.2,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SOTALOL HCL 80 MG PO TABS",0250,A9270,60505008000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE 100 MG PO TABS",0250,A9270,60687048701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE 100 MG PO TABS",0250,A9270,60687048711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE 50 MG PO TABS",0250,A9270,60687047601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE 50 MG PO TABS",0250,A9270,60687047611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE HCL-NALOXONE HCL 4-1 MG SL FILM",0250,J0572,43598058030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,23.83 ,16.68 ,Aetna,"AETNA",8.98,191,fee schedule,999999999,7.149,16.681,fee schedule,"191% of Drug Fee Schedule"
"BUPRENORPHINE HCL-NALOXONE HCL 4-1 MG SL FILM",0250,J0572,43598058001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,23.83 ,16.68 ,Aetna,"AETNA",8.98,191,fee schedule,999999999,7.149,16.681,fee schedule,"191% of Drug Fee Schedule"
"SUCCIMER 100 MG PO CAPS",0250,A9270,55292020111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,132.21 ,92.55 ,Aetna,"AETNA",59.49,45,percent of total billed charges,999999999,0.03087,92.547,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCRALFATE 1 GM/10ML PO SUSP",0250,A9270,50268074511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,37.10 ,25.97 ,Aetna,"AETNA",16.70,45,percent of total billed charges,999999999,0.03087,27.048,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCRALFATE 1 GM/10ML PO SUSP",0250,A9270,50268074514,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,38.64 ,27.05 ,Aetna,"AETNA",17.39,45,percent of total billed charges,999999999,0.03087,27.048,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCRALFATE 1 G PO TABS",0250,A9270,51079075320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCRALFATE 1 G PO TABS",0250,A9270,51079075301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUFENTANIL CITRATE 50 MCG/ML IV SOLN",0250,,00409338221,RC,,NDC,FACILITY,OUTPATIENT,0.2,ML,,9.14 ,6.40 ,Aetna,"AETNA",4.11,45,percent of total billed charges,999999999,2.742,6.398,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TEMAZEPAM 7.5 MG PO CAPS",0250,A9270,00904643604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,18.37 ,12.86 ,Aetna,"AETNA",8.27,45,percent of total billed charges,999999999,0.03087,12.859,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERBUTALINE SULFATE 1 MG/ML INJ SOLN",0250,J3105,00143974610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",11.63,191,fee schedule,999999999,1.5,14.3,fee schedule,"191% of Drug Fee Schedule"
"TERBUTALINE SULFATE 1 MG/ML INJ SOLN",0250,J3105,00143974601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",11.63,191,fee schedule,999999999,1.5,14.3,fee schedule,"191% of Drug Fee Schedule"
"TERBUTALINE SULFATE 2.5 MG PO TABS",0250,A9270,00115261101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.55 ,10.19 ,Aetna,"AETNA",6.55,45,percent of total billed charges,999999999,0.03087,10.185,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERCONAZOLE 0.4 % VA CREA",0250,A9270,51672130406,RC,HCPCS,NDC,FACILITY,OUTPATIENT,45,GR,,123.66 ,86.56 ,Aetna,"AETNA",55.65,45,percent of total billed charges,999999999,0.03087,174.447,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERCONAZOLE 0.4 % VA CREA",0250,A9270,00062535001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,45,GR,,249.21 ,174.45 ,Aetna,"AETNA",112.14,45,percent of total billed charges,999999999,0.03087,174.447,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFUVITE ADULT IV INJ",0250,,54643564901,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,37.14 ,26.00 ,Aetna,"AETNA",16.71,45,percent of total billed charges,999999999,11.142,25.998,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETANUS-DIPHTHERIA TOXOIDS TD 5-2 LFU IM INJ",0250,90714,49281021515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,35.88 ,25.12 ,Aetna,"AETNA",16.15,45,percent of total billed charges,999999999,8.97,25.116,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETRACAINE HCL 1 % INJ SOLN",0250,,54288012701,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,223.46 ,156.42 ,Aetna,"AETNA",100.56,45,percent of total billed charges,999999999,67.038,156.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETRACAINE HCL 1 % INJ SOLN",0250,,54288012710,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,223.46 ,156.42 ,Aetna,"AETNA",100.56,45,percent of total billed charges,999999999,67.038,156.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"APIXABAN 2.5 MG PO TABS",0250,A9270,00003089331,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.78 ,6.85 ,Aetna,"AETNA",4.40,45,percent of total billed charges,999999999,0.03087,6.846,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"APIXABAN 5 MG PO TABS",0250,A9270,00003089431,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.78 ,6.85 ,Aetna,"AETNA",4.40,45,percent of total billed charges,999999999,0.03087,6.846,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THROMBIN 5000 UNITS EX SOLR",0250,,60793021505,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,232.50 ,162.75 ,Aetna,"AETNA",104.63,45,percent of total billed charges,999999999,69.75,162.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVONORGESTREL 13.5 MG IU IUD",0250,J7301,50419042201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,13.5,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",2207.69,191,fee schedule,999999999,900,2207.6926,fee schedule,"191% of Drug Fee Schedule"
"TIMOLOL MALEATE 0.25 % OP SOLN",0250,,61314022605,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,15.75 ,11.03 ,Aetna,"AETNA",7.09,45,percent of total billed charges,999999999,4.725,11.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIMOLOL MALEATE 0.5 % OP SOLN",0250,,61314022705,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,30.73 ,21.51 ,Aetna,"AETNA",13.83,45,percent of total billed charges,999999999,9.219,21.511,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN SULFATE 1.2 G INJ SOLR",0250,J3260,72266016301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,223.37 ,156.36 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.6,156.359,fee schedule,"191% of Drug Fee Schedule"
"TOBRAMYCIN SULFATE 1.2 G INJ SOLR",0250,J3260,72266016306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,223.37 ,156.36 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.6,156.359,fee schedule,"191% of Drug Fee Schedule"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT",0250,,00078087601,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,1262.75 ,883.93 ,Aetna,"AETNA",568.24,45,percent of total billed charges,999999999,378.825,883.925,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP",0250,,00574403125,RC,,NDC,FACILITY,OUTPATIENT,2.5,ML,,131.76 ,92.23 ,Aetna,"AETNA",59.29,45,percent of total billed charges,999999999,39.528,92.232,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMTERENE 50 MG PO CAPS",0250,A9270,66993083102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,49.20 ,34.44 ,Aetna,"AETNA",22.14,45,percent of total billed charges,999999999,0.03087,34.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIFLURIDINE 1 % OP SOLN",0250,A9270,61314004475,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ML,,749.21 ,524.45 ,Aetna,"AETNA",337.14,45,percent of total billed charges,999999999,0.03087,524.447,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN",0250,,61314062810,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,38.01 ,26.61 ,Aetna,"AETNA",17.10,45,percent of total billed charges,999999999,11.403,26.607,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS",0250,A9270,00904272561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR",0250,J9354,50242008801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,11630.88 ,8141.62 ,Aetna,"AETNA",73.42,191,fee schedule,999999999,35.7,8141.616,fee schedule,"191% of Drug Fee Schedule"
"ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR",0250,J9354,50242008701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,18609.39 ,13026.57 ,Aetna,"AETNA",73.42,191,fee schedule,999999999,35.7,13026.573,fee schedule,"191% of Drug Fee Schedule"
"MORPHINE SULFATE ER 30 MG PO TBCR",0250,A9270,00904655861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"URSODIOL 300 MG PO CAPS",0250,A9270,69238154001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCOPYRROLATE 0.4 MG/2ML INJ SOLN",0250,J1596,00143968125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,14.60 ,10.22 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,54.726,fee schedule,"191% of Drug Fee Schedule"
"GLYCOPYRROLATE 0.4 MG/2ML INJ SOLN",0250,J1596,00143968101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,78.18 ,54.73 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,54.726,fee schedule,"191% of Drug Fee Schedule"
"ATRACURIUM BESYLATE 50 MG/5ML IV SOLN",0250,,00409110901,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,40.92 ,28.64 ,Aetna,"AETNA",18.41,45,percent of total billed charges,999999999,12.276,28.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATRACURIUM BESYLATE 50 MG/5ML IV SOLN",0250,,00409110911,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,40.92 ,28.64 ,Aetna,"AETNA",18.41,45,percent of total billed charges,999999999,12.276,28.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATRACURIUM BESYLATE 100 MG/10ML IV SOLN",0250,,71288070210,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,41.09 ,28.76 ,Aetna,"AETNA",18.49,45,percent of total billed charges,999999999,12.327,28.763,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATRACURIUM BESYLATE 100 MG/10ML IV SOLN",0250,,71288070211,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,41.09 ,28.76 ,Aetna,"AETNA",18.49,45,percent of total billed charges,999999999,12.327,28.763,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE ER 15 MG PO TBCR",0250,A9270,00904655761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE ER 60 MG PO TBCR",0250,A9270,42858080301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE ER 100 MG PO TBCR",0250,A9270,00904656061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,20.77 ,14.54 ,Aetna,"AETNA",9.35,45,percent of total billed charges,999999999,0.03087,14.539,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCOPYRROLATE 1 MG/5ML INJ SOLN",0250,J1596,71288041505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,16.42 ,11.49 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,11.494,fee schedule,"191% of Drug Fee Schedule"
"GLYCOPYRROLATE 1 MG/5ML INJ SOLN",0250,J1596,71288041506,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,16.42 ,11.49 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,11.494,fee schedule,"191% of Drug Fee Schedule"
"VANCOMYCIN HCL 10 G IV SOLR",0250,J3370,00409651001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,160.56 ,112.39 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,112.392,fee schedule,"191% of Drug Fee Schedule"
"VECURONIUM BROMIDE 10 MG IV SOLR",0250,J3490,47335093144,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12.65 ,8.86 ,Aetna,"AETNA",5.69,45,percent of total billed charges,999999999,0,8.855,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VECURONIUM BROMIDE 10 MG IV SOLR",0250,J3490,47335093140,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12.65 ,8.86 ,Aetna,"AETNA",5.69,45,percent of total billed charges,999999999,0,8.855,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VECURONIUM BROMIDE 20 MG IV SOLR",0250,J3490,00143923201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,15.10 ,10.57 ,Aetna,"AETNA",6.80,45,percent of total billed charges,999999999,0,10.57,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VECURONIUM BROMIDE 20 MG IV SOLR",0250,J3490,00143923210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,15.10 ,10.57 ,Aetna,"AETNA",6.80,45,percent of total billed charges,999999999,0,10.57,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 1 MG PO TABS",0250,A9270,00832121101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIDOVUDINE 10 MG/ML IV SOLN",0250,J3485,49702021305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,165.12 ,115.58 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.51,115.584,fee schedule,"191% of Drug Fee Schedule"
"ZIDOVUDINE 10 MG/ML IV SOLN",0250,J3485,49702021301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,165.12 ,115.58 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.51,115.584,fee schedule,"191% of Drug Fee Schedule"
"ZIDOVUDINE 100 MG PO CAPS",0250,A9270,65862010701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.13 ,9.89 ,Aetna,"AETNA",6.36,45,percent of total billed charges,999999999,0.03087,9.891,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIDOVUDINE 10 MG/ML PO SYRP",0250,A9270,65862004824,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.82 ,8.27 ,Aetna,"AETNA",5.32,45,percent of total billed charges,999999999,0.03087,8.274,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZOLPIDEM TARTRATE 5 MG PO TABS",0250,A9270,00904608261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXMEDETOMIDINE HCL IN NACL 200 MCG/50ML IV SOLN",0250,,00338955524,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,116.70 ,81.69 ,Aetna,"AETNA",52.52,45,percent of total billed charges,999999999,35.01,81.69,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXMEDETOMIDINE HCL IN NACL 400 MCG/100ML IV SOLN",0250,,99999030599,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 200 MCG IV SOLR",0250,,63323064710,RC,,NDC,FACILITY,OUTPATIENT,0.5,UN  ,,491.53 ,344.07 ,Aetna,"AETNA",221.19,45,percent of total billed charges,999999999,147.459,344.071,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VINCRISTINE SULFATE LIPOSOME 5 MG/31ML IV SUSP",0250,J9371,20536032201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,46987.08 ,32890.96 ,Aetna,"AETNA",7882.97,191,fee schedule,999999999,3420.78,32890.956,fee schedule,"191% of Drug Fee Schedule"
"PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT",0250,,63833038602,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,750,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAMETINIB DIMETHYL SULFOXIDE 0.5 MG PO TABS",0250,J8999,00078110515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,0,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN",0250,J2710,42023018901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.8,3.5,fee schedule,"191% of Drug Fee Schedule"
"NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN",0250,J2710,42023018910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.8,3.5,fee schedule,"191% of Drug Fee Schedule"
"BUPIVACAINE HCL (PF) 0.75 % INJ SOLN",0250,J0665,55150017110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,8.68 ,6.08 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,6.076,fee schedule,"191% of Drug Fee Schedule"
"MILRINONE LACTATE 10 MG/10ML IV SOLN",0250,J2260,71288020010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,20.51 ,14.36 ,Aetna,"AETNA",2.96,191,fee schedule,999999999,1.562,14.357,fee schedule,"191% of Drug Fee Schedule"
"MILRINONE LACTATE 10 MG/10ML IV SOLN",0250,J2260,71288020011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,20.51 ,14.36 ,Aetna,"AETNA",2.96,191,fee schedule,999999999,1.562,14.357,fee schedule,"191% of Drug Fee Schedule"
"MILRINONE LACTATE 20 MG/20ML IV SOLN",0250,J2260,00143970910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,38.78 ,27.15 ,Aetna,"AETNA",2.96,191,fee schedule,999999999,1.562,27.342,fee schedule,"191% of Drug Fee Schedule"
"MILRINONE LACTATE 20 MG/20ML IV SOLN",0250,J2260,63323061720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,39.06 ,27.34 ,Aetna,"AETNA",2.96,191,fee schedule,999999999,1.562,27.342,fee schedule,"191% of Drug Fee Schedule"
"ETOPOSIDE 500 MG/25ML IV SOLN",0250,J9181,63323010425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,112.50 ,78.75 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.7,78.75,fee schedule,"191% of Drug Fee Schedule"
"ETOPOSIDE 1 GM/50ML IV SOLN",0250,J9181,16729011411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,576.90 ,403.83 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.7,403.83,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM GLUCONATE 500 (27 MG) MG PO TABS",0250,A9270,60258017201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL ER 10 MG PO T12A",0250,A9270,59011041020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,29.97 ,20.98 ,Aetna,"AETNA",13.49,45,percent of total billed charges,999999999,0.03087,20.979,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL ER 20 MG PO T12A",0250,A9270,59011042020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,55.84 ,39.09 ,Aetna,"AETNA",25.13,45,percent of total billed charges,999999999,0.03087,39.088,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL ER 40 MG PO T12A",0250,A9270,59011044020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,81.94 ,57.36 ,Aetna,"AETNA",36.87,45,percent of total billed charges,999999999,0.03087,57.358,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GOLIMUMAB 50 MG/4ML IV SOLN",0250,J1602,57894035001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9741.20 ,6818.84 ,Aetna,"AETNA",22.54,191,fee schedule,999999999,12.341,6818.84,fee schedule,"191% of Drug Fee Schedule"
"CLOBAZAM 2.5 MG/ML PO SUSP",0250,A9270,69238153502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOLUTEGRAVIR SODIUM 50 MG PO TABS",0250,A9270,49702022813,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,440.20 ,308.14 ,Aetna,"AETNA",198.09,45,percent of total billed charges,999999999,0.03087,308.14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN",0250,,55150020902,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,11.89 ,8.32 ,Aetna,"AETNA",5.35,45,percent of total billed charges,999999999,3.567,8.323,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BORTEZOMIB 3.5 MG INJ SOLR",0250,J9041,50742048401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,362.10 ,253.47 ,Aetna,"AETNA",3.95,191,fee schedule,999999999,1.959,253.47,fee schedule,"191% of Drug Fee Schedule"
"HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR",0250,90648,49281054503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,17.5,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOTAL B/C PO TABS",0250,A9270,80681015400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORTIOXETINE HBR 10 MG PO TABS",0250,A9270,64764073030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,91.19 ,63.83 ,Aetna,"AETNA",41.04,45,percent of total billed charges,999999999,0.03087,63.833,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORTIOXETINE HBR 20 MG PO TABS",0250,A9270,64764075030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,45.59 ,31.91 ,Aetna,"AETNA",20.52,45,percent of total billed charges,999999999,0.03087,31.913,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOCILIZUMAB 162 MG/0.9ML SC SOSY",0250,J3262,50242013801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3336.24 ,2335.37 ,Aetna,"AETNA",11.54,191,fee schedule,999999999,5.91,2335.368,fee schedule,"191% of Drug Fee Schedule"
"PHENYLEPHRINE-MINERAL OIL-PET 0.25-14-74.9 % PR OINT",0250,A9270,00536128806,RC,HCPCS,NDC,FACILITY,OUTPATIENT,57,GR,,14.36 ,10.05 ,Aetna,"AETNA",6.46,45,percent of total billed charges,999999999,0.03087,10.052,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PERAMPANEL 2 MG PO TABS",0250,A9270,69616027230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,115.83 ,81.08 ,Aetna,"AETNA",52.12,45,percent of total billed charges,999999999,0.03087,81.081,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TBO-FILGRASTIM 300 MCG/0.5ML SC SOSY",0250,J1447,63459091011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,409.26 ,286.48 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.39,286.482,fee schedule,"191% of Drug Fee Schedule"
"TBO-FILGRASTIM 480 MCG/0.8ML SC SOSY",0250,J1447,63459091211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,655.02 ,458.51 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.39,458.514,fee schedule,"191% of Drug Fee Schedule"
"OBINUTUZUMAB 1000 MG/40ML IV SOLN",0250,J9301,50242007001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,24631.56 ,17242.09 ,Aetna,"AETNA",134.12,191,fee schedule,999999999,67.35,17242.092,fee schedule,"191% of Drug Fee Schedule"
"ANTICOAGULANT CIT DEXT SOLN A 0.8-2.45-2.2 GM/100ML VI SOLN",0250,,00942064103,RC,,NDC,FACILITY,OUTPATIENT,750,ML,,69.09 ,48.36 ,Aetna,"AETNA",31.09,45,percent of total billed charges,999999999,20.727,53.55,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANTICOAGULANT CIT DEXT SOLN A 0.8-2.45-2.2 GM/100ML VI SOLN",0250,,14537096775,RC,,NDC,FACILITY,OUTPATIENT,750,ML,,76.50 ,53.55 ,Aetna,"AETNA",34.43,45,percent of total billed charges,999999999,20.727,53.55,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POSACONAZOLE 100 MG PO TBEC",0250,A9270,70748025807,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,37.48 ,26.24 ,Aetna,"AETNA",16.87,45,percent of total billed charges,999999999,0.03087,26.236,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MECLIZINE HCL 12.5 MG PO TABS",0250,A9270,00904737561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MECLIZINE HCL 25 MG PO TABS",0250,A9270,00904737661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESLICARBAZEPINE ACETATE 600 MG PO TABS",0250,A9270,63402020660,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,212.98 ,149.09 ,Aetna,"AETNA",95.84,45,percent of total billed charges,999999999,0.03087,149.086,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESLICARBAZEPINE ACETATE 800 MG PO TABS",0250,A9270,63402020830,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,212.98 ,149.09 ,Aetna,"AETNA",95.84,45,percent of total billed charges,999999999,0.03087,149.086,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS",0250,A9270,00310621039,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,73.57 ,51.50 ,Aetna,"AETNA",33.11,45,percent of total billed charges,999999999,0.03087,51.499,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ELOSULFASE ALFA 5 MG/5ML IV SOLN",0250,J1322,68135010001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,4182.00 ,2927.40 ,Aetna,"AETNA",540.95,191,fee schedule,999999999,262.67,2927.4,fee schedule,"191% of Drug Fee Schedule"
"THEOPHYLLINE ER 300 MG PO TB12",0250,A9270,62332002531,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.92 ,11.84 ,Aetna,"AETNA",7.61,45,percent of total billed charges,999999999,0.03087,11.844,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN 0.3 % OP SOLN",0250,,62332051805,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,48.44 ,33.91 ,Aetna,"AETNA",21.80,45,percent of total billed charges,999999999,14.532,33.908,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETOPOSIDE 100 MG/5ML IV SOLN",0250,J9181,00703565301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,103.98 ,72.79 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.7,72.786,fee schedule,"191% of Drug Fee Schedule"
"HYLAN G-F 20 16 MG/2ML IX SOSY",0250,J7325,58468009001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,450.00 ,315.00 ,Aetna,"AETNA",16.96,191,fee schedule,999999999,8.77,315,fee schedule,"191% of Drug Fee Schedule"
"INSULIN ASPART 100 UNIT/ML SC SOPN",0250,J1815,00169633910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,156.10 ,109.27 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,109.27,fee schedule,"191% of Drug Fee Schedule"
"INSULIN GLARGINE 100 UNIT/ML SC SOPN",0250,J1815,00088221905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,102.80 ,71.96 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,82.124,fee schedule,"191% of Drug Fee Schedule"
"INSULIN GLARGINE 100 UNIT/ML SC SOPN",0250,J1815,00088221901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,117.32 ,82.12 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,82.124,fee schedule,"191% of Drug Fee Schedule"
"INSULIN GLULISINE 100 UNIT/ML SC SOPN",0250,J1815,00088250205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,182.03 ,127.42 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,127.421,fee schedule,"191% of Drug Fee Schedule"
"INSULIN GLULISINE 100 UNIT/ML SC SOPN",0250,J1815,00088250200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,182.03 ,127.42 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,127.421,fee schedule,"191% of Drug Fee Schedule"
"EXENATIDE 5 MCG/0.02ML SC SOPN",0250,C9399,00310651201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.2,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,750,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EXENATIDE 10 MCG/0.04ML SC SOPN",0250,C9399,00310652401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.4,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,750,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML INJ SOLN",0250,J1100,63323016505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,"191% of Drug Fee Schedule"
"PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT",0250,J7168,63833038702,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10081.68 ,7057.18 ,Aetna,"AETNA",6.84,191,fee schedule,999999999,2.98,7057.176,fee schedule,"191% of Drug Fee Schedule"
"TOBRAMYCIN 0.3 % OP OINT",0250,A9270,00078081301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.5,GR,,1186.15 ,830.31 ,Aetna,"AETNA",533.77,45,percent of total billed charges,999999999,0.03087,830.305,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RAMUCIRUMAB 100 MG/10ML IV SOLN",0250,J9308,00002766901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,4268.40 ,2987.88 ,Aetna,"AETNA",133.03,191,fee schedule,999999999,65.62,2987.88,fee schedule,"191% of Drug Fee Schedule"
"RAMUCIRUMAB 500 MG/50ML IV SOLN",0250,J9308,00002767801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,21342.00 ,14939.40 ,Aetna,"AETNA",133.03,191,fee schedule,999999999,65.62,14939.4,fee schedule,"191% of Drug Fee Schedule"
"SILTUXIMAB 100 MG IV SOLR",0250,J2860,57894042001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3519.78 ,2463.85 ,Aetna,"AETNA",289.00,191,fee schedule,999999999,132,2463.846,fee schedule,"191% of Drug Fee Schedule"
"SILTUXIMAB 400 MG IV SOLR",0250,J2860,57894042101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14079.09 ,9855.36 ,Aetna,"AETNA",289.00,191,fee schedule,999999999,132,9855.363,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM CHLORIDE ER 10 MEQ PO TBCR",0250,A9270,60687069701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE ER 10 MEQ PO TBCR",0250,A9270,60687069711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETYLCYSTEINE 10 % INH SOLN",0250,J7608,00409330703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,79.74 ,55.82 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,6.825,55.818,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 10 % INH SOLN",0250,J7608,00517750425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,70.00 ,49.00 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,6.825,55.818,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 10 % INH SOLN",0250,J7608,00517751003,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,28.00 ,19.60 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,6.825,55.818,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 10 % INH SOLN",0250,J7608,00409330711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,71.10 ,49.77 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,6.825,55.818,fee schedule,"191% of Drug Fee Schedule"
"VENLAFAXINE HCL 25 MG PO TABS",0250,A9270,57237017201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENLAFAXINE HCL 50 MG PO TABS",0250,A9270,57237017401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENLAFAXINE HCL 75 MG PO TABS",0250,A9270,57237017501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENLAFAXINE HCL 37.5 MG PO TABS",0250,A9270,57237017301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DORNASE ALFA 2.5 MG/2.5ML INH SOLN",0250,J7639,50242010039,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,704.45 ,493.12 ,Aetna,"AETNA",99.38,191,fee schedule,999999999,50.16,507.906,fee schedule,"191% of Drug Fee Schedule"
"DORNASE ALFA 2.5 MG/2.5ML INH SOLN",0250,J7639,50242010040,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,725.58 ,507.91 ,Aetna,"AETNA",99.38,191,fee schedule,999999999,50.16,507.906,fee schedule,"191% of Drug Fee Schedule"
"CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR",0250,A9270,16729007801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VEDOLIZUMAB 300 MG IV SOLR",0250,J3380,64764030020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,25900.95 ,18130.67 ,Aetna,"AETNA",41.73,191,fee schedule,999999999,22.063,18130.665,fee schedule,"191% of Drug Fee Schedule"
"DALBAVANCIN HCL 500 MG IV SOLR",0250,J0875,57970010001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",28.88,191,fee schedule,999999999,14.7,2100,fee schedule,"191% of Drug Fee Schedule"
"COLESTIPOL HCL 5 G PO PACK",0250,A9270,00009026001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,46.21 ,32.35 ,Aetna,"AETNA",20.79,45,percent of total billed charges,999999999,0.03087,32.347,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPHOSPHAMIDE 50 MG PO CAPS",0250,J8530,00054038325,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,20.43 ,14.30 ,Aetna,"AETNA",1.64,191,fee schedule,999999999,0.58,14.301,fee schedule,"191% of Drug Fee Schedule"
"CETIRIZINE HCL 1 MG/ML PO SOLN",0250,A9270,51672407008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BELINOSTAT 500 MG IV SOLR",0250,J9032,68152010809,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5740.74 ,4018.52 ,Aetna,"AETNA",93.28,191,fee schedule,999999999,44.36,4018.518,fee schedule,"191% of Drug Fee Schedule"
"HYALURONAN 30 MG/2ML IX SOSY",0250,J7324,59676036001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,1112.68 ,778.88 ,Aetna,"AETNA",251.28,191,fee schedule,999999999,117.38,778.876,fee schedule,"191% of Drug Fee Schedule"
"TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN",0250,J1071,00009041701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,16.12 ,11.28 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,11.284,fee schedule,"191% of Drug Fee Schedule"
"LITHIUM 8 MEQ/5ML PO SOLN",0250,,00054352763,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,38.85 ,27.20 ,Aetna,"AETNA",17.48,45,percent of total billed charges,999999999,11.655,27.195,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONABOTULINUMTOXINA 100 UNITS INJ SOLR",0250,J0585,00023114501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2536.00 ,1775.20 ,Aetna,"AETNA",12.07,191,fee schedule,999999999,6.09,1775.2,fee schedule,"191% of Drug Fee Schedule"
"OLODATEROL HCL 2.5 MCG/ACT INH AERS",0250,A9270,00597019261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,GR,,1211.16 ,847.81 ,Aetna,"AETNA",545.02,45,percent of total billed charges,999999999,0.03087,847.812,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETYLCYSTEINE 20 % INH SOLN",0250,J7608,63323069030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,5.00 ,3.50 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,1.5,24.325,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 20 % INH SOLN",0250,J7608,63323069210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,13.90 ,9.73 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,1.5,24.325,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 20 % INH SOLN",0250,J7608,63323069404,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,34.75 ,24.33 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,1.5,24.325,fee schedule,"191% of Drug Fee Schedule"
"ACETYLCYSTEINE 20 % INH SOLN",0250,J7608,63323069441,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,34.75 ,24.33 ,Aetna,"AETNA",17.88,191,fee schedule,999999999,1.5,24.325,fee schedule,"191% of Drug Fee Schedule"
"PROGESTERONE 100 MG PO CAPS",0250,A9270,59651015201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT INH AERS",0250,A9270,00597010051,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,GR,,244.44 ,171.11 ,Aetna,"AETNA",110.00,45,percent of total billed charges,999999999,0.03087,171.108,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICARDIPINE HCL 2.5 MG/ML IV SOLN",0250,,00143968910,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,63.91 ,44.74 ,Aetna,"AETNA",28.76,45,percent of total billed charges,999999999,2.106,44.737,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICARDIPINE HCL 2.5 MG/ML IV SOLN",0250,,00143968901,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7.02 ,4.91 ,Aetna,"AETNA",3.16,45,percent of total billed charges,999999999,2.106,44.737,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MENINGOCOCCAL B VAC (RECOMB) IM SUSY",0250,90621,00005010001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,814.28 ,570.00 ,Aetna,"AETNA",366.43,45,percent of total billed charges,999999999,200.7725,569.996,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MENINGOCOCCAL B VAC (RECOMB) IM SUSY",0250,90621,00005010005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,803.09 ,562.16 ,Aetna,"AETNA",361.39,45,percent of total billed charges,999999999,200.7725,569.996,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VASOPRESSIN 20 UNIT/ML IV SOLN",0250,J2598,70121164201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.78 ,21.55 ,Aetna,"AETNA",3.59,191,fee schedule,999999999,1.815,21.546,fee schedule,"191% of Drug Fee Schedule"
"VASOPRESSIN 20 UNIT/ML IV SOLN",0250,J2598,70121164205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,26.47 ,18.53 ,Aetna,"AETNA",3.59,191,fee schedule,999999999,1.815,21.546,fee schedule,"191% of Drug Fee Schedule"
"ALEMTUZUMAB 12 MG/1.2ML IV SOLN",0250,J0202,58468020001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,59250.00 ,41475.00 ,Aetna,"AETNA",4483.88,191,fee schedule,999999999,2207.16,41475,fee schedule,"191% of Drug Fee Schedule"
"HPV 9-VALENT RECOMB VACCINE IM SUSP",0250,90649,00006411901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,172.80 ,120.96 ,Aetna,"AETNA",77.76,45,percent of total billed charges,999999999,43.2,120.96,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLINATUMOMAB 35 MCG IV SOLR",0250,J9039,55513016001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,15375.30 ,10762.71 ,Aetna,"AETNA",277.64,191,fee schedule,999999999,131.9,10762.71,fee schedule,"191% of Drug Fee Schedule"
"CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR",0250,J0695,67919003001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,75,ME,,87.51 ,61.26 ,Aetna,"AETNA",13.92,191,fee schedule,999999999,6.35,61.257,fee schedule,"191% of Drug Fee Schedule"
"NIVOLUMAB 40 MG/4ML IV SOLN",0250,J9299,00003377211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3728.26 ,2609.78 ,Aetna,"AETNA",59.38,191,fee schedule,999999999,29.55,2609.782,fee schedule,"191% of Drug Fee Schedule"
"NIVOLUMAB 100 MG/10ML IV SOLN",0250,J9299,00003377412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9320.61 ,6524.43 ,Aetna,"AETNA",59.38,191,fee schedule,999999999,29.55,6524.427,fee schedule,"191% of Drug Fee Schedule"
"EDOXABAN TOSYLATE 60 MG PO TABS",0250,A9270,65597020330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.82 ,53.77 ,Aetna,"AETNA",34.57,45,percent of total billed charges,999999999,0.03087,53.774,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEMBROLIZUMAB 100 MG/4ML IV SOLN",0250,J9271,00006302602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,16609.20 ,11626.44 ,Aetna,"AETNA",109.46,191,fee schedule,999999999,54.55,11626.44,fee schedule,"191% of Drug Fee Schedule"
"LIDOCAINE 4 % EX PTCH",0250,,70000055701,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.48 ,4.54 ,Aetna,"AETNA",2.92,45,percent of total billed charges,999999999,1.944,5.194,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 4 % EX PTCH",0250,,00536120207,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.42 ,5.19 ,Aetna,"AETNA",3.34,45,percent of total billed charges,999999999,1.944,5.194,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN",0250,,00781304095,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,177.34 ,124.14 ,Aetna,"AETNA",79.80,45,percent of total billed charges,999999999,51.135,124.138,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN",0250,,00781304072,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,170.45 ,119.32 ,Aetna,"AETNA",76.70,45,percent of total billed charges,999999999,51.135,124.138,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHOCARBAMOL 1000 MG/10ML INJ SOLN",0250,J2800,63323077810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,38.64 ,27.05 ,Aetna,"AETNA",11.78,191,fee schedule,999999999,5.656,27.048,fee schedule,"191% of Drug Fee Schedule"
"METHOCARBAMOL 1000 MG/10ML INJ SOLN",0250,J2800,63323077821,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,38.64 ,27.05 ,Aetna,"AETNA",11.78,191,fee schedule,999999999,5.656,27.048,fee schedule,"191% of Drug Fee Schedule"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY",0250,90686,49281042350,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,24.85 ,17.40 ,Aetna,"AETNA",11.18,45,percent of total billed charges,999999999,6.2125,17.395,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY",0250,90686,49281042388,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,24.85 ,17.40 ,Aetna,"AETNA",11.18,45,percent of total billed charges,999999999,6.2125,17.395,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISAVUCONAZONIUM SULFATE 186 MG PO CAPS",0250,A9270,00469032014,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,792.72 ,554.90 ,Aetna,"AETNA",356.72,45,percent of total billed charges,999999999,0.03087,554.904,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISAVUCONAZONIUM SULFATE 372 MG IV SOLR",0250,J1833,00469042099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1702.45 ,1191.72 ,Aetna,"AETNA",2.37,191,fee schedule,999999999,0.98,1191.715,fee schedule,"191% of Drug Fee Schedule"
"PEGASPARGASE 750 UNIT/ML INJ SOLN",0250,J9266,72694095401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76614.72 ,53630.30 ,Aetna,"AETNA",49242.59,191,fee schedule,999999999,22984.416,53630.304,fee schedule,"191% of Drug Fee Schedule"
"ARGINAID PO PACK",0250,,43900035980,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.07 ,5.65 ,Aetna,"AETNA",3.63,45,percent of total billed charges,999999999,2.4,5.649,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARGINAID PO PACK",0250,,43900035988,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.649,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN",0250,,00409337504,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,17.75 ,12.43 ,Aetna,"AETNA",7.99,45,percent of total billed charges,999999999,5.325,12.425,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN",0250,,00409337514,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,17.75 ,12.43 ,Aetna,"AETNA",7.99,45,percent of total billed charges,999999999,5.325,12.425,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GRANISETRON HCL 1 MG/ML IV SOLN",0250,J1626,67457086301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,mcg,,119.94 ,83.96 ,Aetna,"AETNA",0.63,191,fee schedule,999999999,0.36,83.958,fee schedule,"191% of Drug Fee Schedule"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD",0250,A9270,00904698516,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IPRATROPIUM BROMIDE 0.02 % INH SOLN",0250,J7644,00487980101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.63,191,fee schedule,999999999,0.21,3.5,fee schedule,"191% of Drug Fee Schedule"
"IPRATROPIUM BROMIDE 0.02 % INH SOLN",0250,J7644,76204010030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.63,191,fee schedule,999999999,0.21,3.5,fee schedule,"191% of Drug Fee Schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 40.5 (36-4.5) G IV SOLR",0250,J2543,00206885910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,464.76 ,325.33 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,325.332,fee schedule,"191% of Drug Fee Schedule"
"CAFFEINE-SODIUM BENZOATE 125-125 MG/ML INJ SOLN",0250,J0706,00517250210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,148.75 ,104.13 ,Aetna,"AETNA",3.92,191,fee schedule,999999999,1.71,104.125,fee schedule,"191% of Drug Fee Schedule"
"CAFFEINE-SODIUM BENZOATE 125-125 MG/ML INJ SOLN",0250,J0706,00517250201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,148.75 ,104.13 ,Aetna,"AETNA",3.92,191,fee schedule,999999999,1.71,104.125,fee schedule,"191% of Drug Fee Schedule"
"SACUBITRIL-VALSARTAN 24-26 MG PO TABS",0250,A9270,00078065920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SACUBITRIL-VALSARTAN 49-51 MG PO TABS",0250,A9270,00078077720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SACUBITRIL-VALSARTAN 97-103 MG PO TABS",0250,A9270,00078069620,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRABECTEDIN 1 MG IV SOLR",0250,,59676061001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,9630.48 ,6741.34 ,Aetna,"AETNA",4333.72,45,percent of total billed charges,999999999,2407.62,6741.336,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MAGNESIUM SULFATE 2 GM/50ML IV SOLN",0250,J3475,00338170840,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,17.50 ,12.25 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,12.25,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM SULFATE 4 GM/100ML IV SOLN",0250,J3475,00264420654,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,22.40 ,15.68 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,15.68,fee schedule,"191% of Drug Fee Schedule"
"ASPARAGINASE ERWINIA CHRYSANTH 10000 UNITS INJ SOLR",0250,J9019,81561041305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12092.52 ,8464.76 ,Aetna,"AETNA",923.87,191,fee schedule,999999999,403.08,8464.764,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM-SNDZ 300 MCG/0.5ML INJ SOSY",0250,Q5101,61314031801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1327.20 ,929.04 ,Aetna,"AETNA",0.80,191,fee schedule,999999999,0.17,929.04,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM-SNDZ 480 MCG/0.8ML INJ SOSY",0250,Q5101,61314032601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2123.55 ,1486.49 ,Aetna,"AETNA",0.80,191,fee schedule,999999999,0.17,1486.485,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM SULFATE 20 GM/500ML IV SOLN",0250,J3475,00409205020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,35.00 ,24.50 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,24.5,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM SULFATE 40 GM/1000ML IV SOLN",0250,J3475,00409316401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,49.00 ,34.30 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,34.3,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM SULFATE 40 GM/1000ML IV SOLN",0250,J3475,00409316412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,49.00 ,34.30 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,34.3,fee schedule,"191% of Drug Fee Schedule"
"PEGFILGRASTIM 6 MG/0.6ML SC SOSY",0250,J2506,55513019001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,12577.50 ,8804.25 ,Aetna,"AETNA",209.62,191,fee schedule,999999999,50.678,8804.25,fee schedule,"191% of Drug Fee Schedule"
"PEGFILGRASTIM 6 MG/0.6ML SC PSKT",0250,J2506,55513019201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,12577.50 ,8804.25 ,Aetna,"AETNA",209.62,191,fee schedule,999999999,50.678,8804.25,fee schedule,"191% of Drug Fee Schedule"
"INTERFERON BETA-1A 30 MCG/0.5ML IM PSKT",0250,Q3027,59627000205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,13517.16 ,9462.01 ,Aetna,"AETNA",103.67,191,fee schedule,999999999,53.15,9462.012,fee schedule,"191% of Drug Fee Schedule"
"CHLORPROMAZINE HCL 50 MG/2ML INJ SOLN",0250,J3230,00641139831,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,141.36 ,98.95 ,Aetna,"AETNA",53.37,191,fee schedule,999999999,29.786,98.952,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 300 MCG/0.5ML INJ SOSY",0250,J1442,55513092410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1625.19 ,1137.63 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1137.633,fee schedule,"191% of Drug Fee Schedule"
"FILGRASTIM 480 MCG/0.8ML INJ SOSY",0250,J1442,55513020910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2500.00 ,1750.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.985,1750,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 100 MCG/0.5ML INJ SOSY",0250,J0882,55513002501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2698.72 ,1889.10 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,2100,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 100 MCG/0.5ML INJ SOSY",0250,J0882,55513002504,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3000.00 ,2100.00 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,2100,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 150 MCG/0.3ML INJ SOSY",0250,J0882,55513002701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3036.07 ,2125.25 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,2374.771,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 150 MCG/0.3ML INJ SOSY",0250,J0882,55513002704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3392.53 ,2374.77 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,2374.771,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 200 MCG/0.4ML INJ SOSY",0250,J0882,55513002801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,4523.37 ,3166.36 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,3166.359,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 300 MCG/0.6ML INJ SOSY",0250,J0882,55513011101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,6785.07 ,4749.55 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,4749.549,fee schedule,"191% of Drug Fee Schedule"
"DARBEPOETIN ALFA 500 MCG/ML INJ SOSY",0250,J0882,55513003201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,11308.44 ,7915.91 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.93,7915.908,fee schedule,"191% of Drug Fee Schedule"
"TICAGRELOR 60 MG PO TABS",0250,A9270,00186077660,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,48.77 ,34.14 ,Aetna,"AETNA",21.95,45,percent of total billed charges,999999999,0.03087,34.139,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IDARUCIZUMAB 2.5 GM/50ML IV SOLN",0250,C9399,00597019705,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,GR,,7294.65 ,5106.26 ,Aetna,"AETNA",3282.59,45,percent of total billed charges,999999999,1823.6625,5106.255,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERBINAFINE HCL 250 MG PO TABS",0250,A9270,69097085907,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IRINOTECAN HCL LIPOSOME 43 MG/10ML IV INJ",0250,J9205,15054004301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8266.47 ,5786.53 ,Aetna,"AETNA",121.17,191,fee schedule,999999999,60.05,5786.529,fee schedule,"191% of Drug Fee Schedule"
"TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS",0250,A9270,00527163201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUGAMMADEX SODIUM 200 MG/2ML IV SOLN",0250,,00006542302,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,537.83 ,376.48 ,Aetna,"AETNA",242.02,45,percent of total billed charges,999999999,161.349,376.481,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PATIROMER SORBITEX CALCIUM 8.4 G PO PACK",0250,A9270,53436008401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,178.84 ,125.19 ,Aetna,"AETNA",80.48,45,percent of total billed charges,999999999,0.03087,125.188,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PATIROMER SORBITEX CALCIUM 8.4 G PO PACK",0250,A9270,53436008430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,178.84 ,125.19 ,Aetna,"AETNA",80.48,45,percent of total billed charges,999999999,0.03087,125.188,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PATIROMER SORBITEX CALCIUM 16.8 G PO PACK",0250,A9270,53436016801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,89.42 ,62.59 ,Aetna,"AETNA",40.24,45,percent of total billed charges,999999999,0.03087,62.594,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PATIROMER SORBITEX CALCIUM 16.8 G PO PACK",0250,A9270,53436016830,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,89.42 ,62.59 ,Aetna,"AETNA",40.24,45,percent of total billed charges,999999999,0.03087,62.594,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN SODIUM-DEXTROSE 2-4 GM/100ML-% IV SOLN",0250,J0689,00338350841,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,39.20 ,27.44 ,Aetna,"AETNA",2.37,191,fee schedule,999999999,1.21,27.44,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM-DEXTROSE 2-4 GM/100ML-% IV SOLN",0250,J0689,99999033999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,21.70 ,15.19 ,Aetna,"AETNA",2.37,191,fee schedule,999999999,1.21,27.44,fee schedule,"191% of Drug Fee Schedule"
"MEPOLIZUMAB 100 MG SC SOLR",0250,,00173088101,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,8819.85 ,6173.90 ,Aetna,"AETNA",3968.93,45,percent of total billed charges,999999999,2204.9625,6173.895,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG PO TABS",0250,A9270,61958190101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,776.33 ,543.43 ,Aetna,"AETNA",349.35,45,percent of total billed charges,999999999,0.03087,543.431,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARATUMUMAB 100 MG/5ML IV SOLN",0250,,57894050205,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,2652.52 ,1856.76 ,Aetna,"AETNA",1193.63,45,percent of total billed charges,999999999,663.13,1856.764,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARATUMUMAB 400 MG/20ML IV SOLN",0250,,57894050220,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,7957.50 ,5570.25 ,Aetna,"AETNA",3580.88,45,percent of total billed charges,999999999,1989.375,5570.25,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REPLETE FIBER PO LIQD",0250,,98716016358,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ELOTUZUMAB 300 MG IV SOLR",0250,J9176,00003229111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,6536.94 ,4575.86 ,Aetna,"AETNA",14.13,191,fee schedule,999999999,6.95,4575.858,fee schedule,"191% of Drug Fee Schedule"
"ELOTUZUMAB 400 MG IV SOLR",0250,J9176,00003452211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8715.84 ,6101.09 ,Aetna,"AETNA",14.13,191,fee schedule,999999999,6.95,6101.088,fee schedule,"191% of Drug Fee Schedule"
"IMPACT ADVANCED RECOVERY PO LIQD",0250,,43900099290,RC,,NDC,FACILITY,OUTPATIENT,178,ML,,37.38 ,26.17 ,Aetna,"AETNA",16.82,45,percent of total billed charges,999999999,11.214,26.166,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PILOCARPINE HCL 5 MG PO TABS",0250,A9270,00527131301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENDAMUSTINE HCL 100 MG/4ML IV SOLN",0250,J9034,63459034804,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5065.12 ,3545.58 ,Aetna,"AETNA",26.42,191,fee schedule,999999999,14.756,3545.584,fee schedule,"191% of Drug Fee Schedule"
"SEBELIPASE ALFA 20 MG/10ML IV SOLN",0250,J2840,25682000701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,30630.00 ,21441.00 ,Aetna,"AETNA",1170.07,191,fee schedule,999999999,510.5,21441,fee schedule,"191% of Drug Fee Schedule"
"SELEXIPAG 1600 MCG PO TABS",0250,A9270,66215061606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2100.20 ,1470.14 ,Aetna,"AETNA",945.09,45,percent of total billed charges,999999999,0.03087,1470.14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARIPRAZINE HCL 1.5 MG PO CAPS",0250,A9270,61874011520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,269.24 ,188.47 ,Aetna,"AETNA",121.16,45,percent of total billed charges,999999999,0.03087,188.468,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARIPRAZINE HCL 3 MG PO CAPS",0250,A9270,61874013020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,269.24 ,188.47 ,Aetna,"AETNA",121.16,45,percent of total billed charges,999999999,0.03087,188.468,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUDESONIDE 3 MG PO CPEP",0250,A9270,00186070210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,130.30 ,91.21 ,Aetna,"AETNA",58.64,45,percent of total billed charges,999999999,0.03087,91.21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LINEZOLID 600 MG/300ML IV SOLN",0250,J2020,55150024251,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,48.30 ,33.81 ,Aetna,"AETNA",6.91,191,fee schedule,999999999,3.298,33.81,fee schedule,"191% of Drug Fee Schedule"
"CLADRIBINE 10 MG/10ML IV SOLN",0250,J9065,63323014010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,597.30 ,418.11 ,Aetna,"AETNA",31.71,191,fee schedule,999999999,15.773,418.11,fee schedule,"191% of Drug Fee Schedule"
"CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN",0250,,00781315380,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,817.80 ,572.46 ,Aetna,"AETNA",368.01,45,percent of total billed charges,999999999,245.34,572.46,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROMETHORPHAN POLISTIREX ER 30 MG/5ML PO SUER",0250,A9270,70000030201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLPREDNISOLONE 4 MG PO TBPK",0250,J7509,59746000103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.227,3.5,fee schedule,"191% of Drug Fee Schedule"
"FOSCARNET SODIUM 6000 MG/250ML IV SOLN",0250,J1455,76310002425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ME,,1512.50 ,1058.75 ,Aetna,"AETNA",159.06,191,fee schedule,999999999,78.8,1058.75,fee schedule,"191% of Drug Fee Schedule"
"LIDOCAINE HCL (PF) 4 % INJ SOLN",0250,,00409428301,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,23.91 ,16.74 ,Aetna,"AETNA",10.76,45,percent of total billed charges,999999999,7.173,16.737,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRANEXAMIC ACID 1000 MG/10ML IV SOLN",0250,,55150018810,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,15.05 ,10.54 ,Aetna,"AETNA",6.77,45,percent of total billed charges,999999999,4.515,10.535,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIVALPROEX SODIUM 125 MG PO CSDR",0250,A9270,00904661561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.38 ,3.77 ,Aetna,"AETNA",2.42,45,percent of total billed charges,999999999,0.03087,3.766,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPTIFIBATIDE 20 MG/10ML IV SOLN",0250,J1327,67457062910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,101.63 ,71.14 ,Aetna,"AETNA",39.82,191,fee schedule,999999999,12.5,71.141,fee schedule,"191% of Drug Fee Schedule"
"TACROLIMUS 1 MG PO CAPS",0250,J7507,00904709761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8.00 ,5.60 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.236,5.6,fee schedule,"191% of Drug Fee Schedule"
"TACROLIMUS 5 MG PO CAPS",0250,J7507,70377001611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.236,3.5,fee schedule,"191% of Drug Fee Schedule"
"DEFIBROTIDE SODIUM 200 MG/2.5ML IV SOLN",0250,J3490,68727080001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,3090.00 ,2163.00 ,Aetna,"AETNA",1390.50,45,percent of total billed charges,999999999,0,2163,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEFIBROTIDE SODIUM 200 MG/2.5ML IV SOLN",0250,J3490,68727080002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,3090.00 ,2163.00 ,Aetna,"AETNA",1390.50,45,percent of total billed charges,999999999,0,2163,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCCINYLCHOLINE CHLORIDE 200 MG/10ML IV SOSY",0250,J0330,70004091029,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,42.75 ,29.93 ,Aetna,"AETNA",1.85,191,fee schedule,999999999,0.81,29.925,fee schedule,"191% of Drug Fee Schedule"
"EMTRICITABINE-TENOFOVIR AF 200-25 MG PO TABS",0250,A9270,61958200202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,429.45 ,300.62 ,Aetna,"AETNA",193.25,45,percent of total billed charges,999999999,0.03087,300.615,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL-NACL 1-0.9 MG/10ML-% IV SOSY",0250,J2371,99999020199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,36.47 ,25.53 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,25.529,fee schedule,"191% of Drug Fee Schedule"
"PHENYLEPHRINE HCL-NACL 1-0.9 MG/10ML-% IV SOSY",0250,J2371,70092119146,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,25.529,fee schedule,"191% of Drug Fee Schedule"
"PHENYLEPHRINE HCL-NACL 1-0.9 MG/10ML-% IV SOSY",0250,J2371,70004081012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,25.50 ,17.85 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,25.529,fee schedule,"191% of Drug Fee Schedule"
"ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT",0250,J7183,68982018201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,6.16 ,4.31 ,Aetna,"AETNA",2.41,191,fee schedule,999999999,1.16,4.312,fee schedule,"191% of Drug Fee Schedule"
"ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT",0250,J7183,68982018202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,6.16 ,4.31 ,Aetna,"AETNA",2.41,191,fee schedule,999999999,1.16,4.312,fee schedule,"191% of Drug Fee Schedule"
"VENETOCLAX 10 MG PO TABS",0250,A9270,00074056111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.02 ,53.21 ,Aetna,"AETNA",34.21,45,percent of total billed charges,999999999,0.03087,53.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENETOCLAX 10 MG PO TABS",0250,A9270,00074056114,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.04 ,53.23 ,Aetna,"AETNA",34.22,45,percent of total billed charges,999999999,0.03087,53.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENETOCLAX 50 MG PO TABS",0250,A9270,00074056611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.04 ,53.23 ,Aetna,"AETNA",34.22,45,percent of total billed charges,999999999,0.03087,53.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENETOCLAX 100 MG PO TABS",0250,A9270,00074057611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.04 ,53.23 ,Aetna,"AETNA",34.22,45,percent of total billed charges,999999999,0.03087,53.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"APREPITANT 125 MG/5ML PO SUSR",0250,J8501,00006306603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,509.25 ,356.48 ,Aetna,"AETNA",6.69,191,fee schedule,999999999,3.12,356.475,fee schedule,"191% of Drug Fee Schedule"
"BRIVARACETAM 50 MG PO TABS",0250,A9270,50474057066,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,133.80 ,93.66 ,Aetna,"AETNA",60.21,45,percent of total billed charges,999999999,0.03087,93.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRIVARACETAM 100 MG PO TABS",0250,A9270,50474077066,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,133.80 ,93.66 ,Aetna,"AETNA",60.21,45,percent of total billed charges,999999999,0.03087,93.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRIVARACETAM 50 MG/5ML IV SOLN",0250,,50474097075,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,32.13 ,22.49 ,Aetna,"AETNA",14.46,45,percent of total billed charges,999999999,9.639,22.491,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARFILZOMIB 30 MG IV SOLR",0250,J9047,76075010201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,4673.94 ,3271.76 ,Aetna,"AETNA",90.11,191,fee schedule,999999999,44.03,3271.758,fee schedule,"191% of Drug Fee Schedule"
"PEPTAMEN INTENSE VHP PO LIQD",0250,,43900072395,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,222.00 ,155.40 ,Aetna,"AETNA",99.90,45,percent of total billed charges,999999999,66.6,155.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CHLORIDE 10 % IV SOLN",0250,J3490,00409492834,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,81.12 ,56.78 ,Aetna,"AETNA",36.50,45,percent of total billed charges,999999999,0,56.784,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CHLORIDE 10 % IV SOLN",0250,J3490,00517671010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,53.27 ,37.29 ,Aetna,"AETNA",23.97,45,percent of total billed charges,999999999,0,56.784,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL ER 240 MG PO TBCR",0250,A9270,68462026001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CITRATE 950 (200 CA) MG PO TABS",0250,A9270,00904506260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LISINOPRIL 2.5 MG PO TABS",0250,A9270,60687065611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LISINOPRIL 2.5 MG PO TABS",0250,A9270,60687065621,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MULTI VITAMIN PO TABS",0250,A9270,00904053913,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN",0250,Q9968,00517037401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,900.00 ,630.00 ,Aetna,"AETNA",21.41,191,fee schedule,999999999,17.96,681.625,fee schedule,"191% of Drug Fee Schedule"
"METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN",0250,Q9968,00517037405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,973.75 ,681.63 ,Aetna,"AETNA",21.41,191,fee schedule,999999999,17.96,681.625,fee schedule,"191% of Drug Fee Schedule"
"CHLOROPROCAINE HCL (PF) 3 % INJ SOLN",0250,J2401,63323047827,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,112.56 ,78.79 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.037,78.792,fee schedule,"191% of Drug Fee Schedule"
"CHLOROPROCAINE HCL (PF) 3 % INJ SOLN",0250,J2401,63323047801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,112.56 ,78.79 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.037,78.792,fee schedule,"191% of Drug Fee Schedule"
"NALOXONE HCL 2 MG/2ML INJ SOSY",0250,J2310,67457099202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,54.74 ,38.32 ,Aetna,"AETNA",15.39,191,fee schedule,999999999,7.288,38.318,fee schedule,"191% of Drug Fee Schedule"
"COAGULATION FACTOR IX (RECOMB) 500 UNITS IV KIT",0250,J7195,58394063403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2478.35 ,1734.85 ,Aetna,"AETNA",3.34,191,fee schedule,999999999,1.63,1734.845,fee schedule,"191% of Drug Fee Schedule"
"COAGULATION FACTOR IX (RECOMB) 1000 UNITS IV KIT",0250,J7195,58394063503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2500.00 ,1750.00 ,Aetna,"AETNA",3.34,191,fee schedule,999999999,1.63,1750,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE 10 % IV SOLN",0250,J0612,63323036061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,24.06 ,16.84 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.05,40.033,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE 10 % IV SOLN",0250,J0612,00143918001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,57.19 ,40.03 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.05,40.033,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE 10 % IV SOLN",0250,J0612,00143918025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,57.19 ,40.03 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.05,40.033,fee schedule,"191% of Drug Fee Schedule"
"VALACYCLOVIR HCL 500 MG PO TABS",0250,A9270,00378427593,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFUVITE PEDIATRIC IV SOLN",0250,,54643564601,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,79.63 ,55.74 ,Aetna,"AETNA",35.83,45,percent of total billed charges,999999999,23.889,55.741,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"USTEKINUMAB 130 MG/26ML IV SOLN",0250,,57894005427,RC,,NDC,FACILITY,OUTPATIENT,9,ML,,1993.65 ,1395.56 ,Aetna,"AETNA",897.14,45,percent of total billed charges,999999999,498.4125,1395.555,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLIXIMAB-DYYB 100 MG IV SOLR",0250,,00069080901,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,2297.80 ,1608.46 ,Aetna,"AETNA",1034.01,45,percent of total billed charges,999999999,574.45,1608.46,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN",0250,,99999042499,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVONORGESTREL 19.5 MG IU IUD",0250,J7296,50419042401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,19.5,ME,,3470.37 ,2429.26 ,Aetna,"AETNA",2651.37,191,fee schedule,999999999,1041.111,2651.3665,fee schedule,"191% of Drug Fee Schedule"
"COENZYME Q10 30 MG PO CAPS",0250,A9270,50268018615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BEZLOTOXUMAB 1000 MG/40ML IV SOLN",0250,J0565,00006302500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11356.68 ,7949.68 ,Aetna,"AETNA",76.15,191,fee schedule,999999999,39.84,7949.676,fee schedule,"191% of Drug Fee Schedule"
"UREA 15 G PO PACK",0250,A9270,62530000011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.38 ,17.77 ,Aetna,"AETNA",11.42,45,percent of total billed charges,999999999,0.03087,17.766,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"UREA 15 G PO PACK",0250,A9270,62530000010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.38 ,17.77 ,Aetna,"AETNA",11.42,45,percent of total billed charges,999999999,0.03087,17.766,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP",0250,90700,49281028658,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,112.20 ,78.54 ,Aetna,"AETNA",50.49,45,percent of total billed charges,999999999,28.05,89.635,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP",0250,90700,49281028610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,128.05 ,89.64 ,Aetna,"AETNA",57.62,45,percent of total billed charges,999999999,28.05,89.635,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THIOTEPA 100 MG INJ SOLR",0250,J9340,65219002920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,5307.27 ,3715.09 ,Aetna,"AETNA",436.17,191,fee schedule,999999999,247.75,3715.089,fee schedule,"191% of Drug Fee Schedule"
"MAGNESIUM SULFATE IN D5W 1-5 GM/100ML-% IV SOLN",0250,J3475,00338170940,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,8.40 ,5.88 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,5.88,fee schedule,"191% of Drug Fee Schedule"
"ATROPINE SULFATE 8 MG/20ML INJ SOLN",0250,J0461,16729051243,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,56.70 ,39.69 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,39.69,fee schedule,"191% of Drug Fee Schedule"
"FAMCICLOVIR 500 MG PO TABS",0250,A9270,00093811956,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,31.83 ,22.28 ,Aetna,"AETNA",14.32,45,percent of total billed charges,999999999,0.03087,22.281,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BERACTANT IN NACL 25-0.9 MG/ML-% INTRATRACHEA SUSP",0250,,00074104004,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,1248.16 ,873.71 ,Aetna,"AETNA",561.67,45,percent of total billed charges,999999999,331.374,873.712,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BERACTANT IN NACL 25-0.9 MG/ML-% INTRATRACHEA SUSP",0250,,00074104008,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,1104.58 ,773.21 ,Aetna,"AETNA",497.06,45,percent of total billed charges,999999999,331.374,873.712,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAMOXINE-CALAMINE 1-8 % EX LOTN",0250,A9270,00395042096,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,28.50 ,19.95 ,Aetna,"AETNA",12.83,45,percent of total billed charges,999999999,0.03087,19.95,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AVELUMAB 200 MG/10ML IV SOLN",0250,J9023,44087353501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5617.53 ,3932.27 ,Aetna,"AETNA",176.73,191,fee schedule,999999999,88.18,3932.271,fee schedule,"191% of Drug Fee Schedule"
"FLUORESCEIN SODIUM 10 % IV SOLN",0250,,14789012205,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,970.90 ,679.63 ,Aetna,"AETNA",436.91,45,percent of total billed charges,999999999,291.27,679.63,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUORESCEIN SODIUM 10 % IV SOLN",0250,,14789012207,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,970.90 ,679.63 ,Aetna,"AETNA",436.91,45,percent of total billed charges,999999999,291.27,679.63,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DUPILUMAB 300 MG/2ML SC SOSY",0250,J3590,00024591401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,5311.74 ,3718.22 ,Aetna,"AETNA",2390.28,45,percent of total billed charges,999999999,1593.522,3718.218,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OCRELIZUMAB 300 MG/10ML IV SOLN",0250,,50242015001,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,58918.41 ,41242.89 ,Aetna,"AETNA",26513.28,45,percent of total billed charges,999999999,14729.6025,41242.887,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ORAL MIX PO SUSP",0250,,38779251208,RC,,NDC,FACILITY,OUTPATIENT,473,ML,,79.46 ,55.62 ,Aetna,"AETNA",35.76,45,percent of total billed charges,999999999,23.838,55.622,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEFAZODONE HCL 100 MG PO TABS",0250,A9270,00093102406,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.80 ,6.86 ,Aetna,"AETNA",4.41,45,percent of total billed charges,999999999,0.03087,6.86,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1.5 % INJ SOLN",0250,,00409477601,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,38.92 ,27.24 ,Aetna,"AETNA",17.51,45,percent of total billed charges,999999999,11.676,27.244,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP",0250,A9270,00121076616,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,62.91 ,44.04 ,Aetna,"AETNA",28.31,45,percent of total billed charges,999999999,0.03087,44.037,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE PF 1 MG/ML INJ SOLN",0250,J0171,54288010310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,29.33 ,20.53 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,20.531,fee schedule,"191% of Drug Fee Schedule"
"EPINEPHRINE PF 1 MG/ML INJ SOLN",0250,J0171,99999057799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,29.33 ,20.53 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,20.531,fee schedule,"191% of Drug Fee Schedule"
"MIDOSTAURIN 25 MG PO CAPS",0250,J8999,00078069819,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1933.29 ,1353.30 ,Aetna,"AETNA",869.98,45,percent of total billed charges,999999999,0,1353.303,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DURVALUMAB 120 MG/2.4ML IV SOLN",0250,,00310450012,RC,,NDC,FACILITY,OUTPATIENT,2.4,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,750,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DURVALUMAB 500 MG/10ML IV SOLN",0250,,00310461150,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,12035.76 ,8425.03 ,Aetna,"AETNA",5416.09,45,percent of total billed charges,999999999,3008.94,8425.032,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAPSAICIN 0.025 % EX CREA",0250,A9270,00536252525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,0.03087,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC RECOM HA QUAD PF 0.5 ML IM SOSY",0250,90682,49281072310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,81.90 ,57.33 ,Aetna,"AETNA",36.86,45,percent of total billed charges,999999999,20.475,57.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC RECOM HA QUAD PF 0.5 ML IM SOSY",0250,90682,49281072388,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,81.90 ,57.33 ,Aetna,"AETNA",36.86,45,percent of total billed charges,999999999,20.475,57.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EDARAVONE 30 MG/100ML IV SOLN",0250,,70510217102,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,625,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESMOPRESSIN ACETATE 1.5 MG/ML NA SOLN",0250,A9270,00053687100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,0.03087,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEMIN 350 MG IV SOLR",0250,J1640,55292070254,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,22345.50 ,15641.85 ,Aetna,"AETNA",59.88,191,fee schedule,999999999,29.03,15641.85,fee schedule,"191% of Drug Fee Schedule"
"CARBAMAZEPINE 100 MG PO CHEW",0250,A9270,00904385461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBAMAZEPINE 100 MG/5ML PO SUSP",0250,A9270,51672404709,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBAMAZEPINE 200 MG PO TABS",0250,A9270,00904617261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAUNORUBICIN-CYTARABINE LIPO 44-100 MG IV SUSR",0250,,68727074502,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,30483.72 ,21338.60 ,Aetna,"AETNA",13717.67,45,percent of total billed charges,999999999,7620.93,21338.604,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INOTUZUMAB OZOGAMICIN 0.9 MG IV SOLR",0250,,00008010001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,66453.00 ,46517.10 ,Aetna,"AETNA",29903.85,45,percent of total billed charges,999999999,16613.25,46517.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GEMTUZUMAB OZOGAMICIN 4.5 MG IV SOLR",0250,J9203,00008451001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,29139.78 ,20397.85 ,Aetna,"AETNA",432.19,191,fee schedule,999999999,214.28,20397.846,fee schedule,"191% of Drug Fee Schedule"
"METHOTREXATE SODIUM 2.5 MG PO TABS",0250,J8610,67253032010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,24.95 ,17.47 ,Aetna,"AETNA",0.46,191,fee schedule,999999999,0.23,17.465,fee schedule,"191% of Drug Fee Schedule"
"METHOTREXATE SODIUM 2.5 MG PO TABS",0250,J8610,51079067005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,17.79 ,12.45 ,Aetna,"AETNA",0.46,191,fee schedule,999999999,0.23,17.465,fee schedule,"191% of Drug Fee Schedule"
"BOSENTAN 32 MG PO TBSO",0250,A9270,66215010314,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1088.10 ,761.67 ,Aetna,"AETNA",489.65,45,percent of total billed charges,999999999,0.03087,761.67,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COPANLISIB HCL 60 MG IV SOLR",0250,,50419038501,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,15700.92 ,10990.64 ,Aetna,"AETNA",7065.41,45,percent of total billed charges,999999999,3925.23,10990.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZELASTINE HCL 137 MCG/SPRAY NA SOLN",0250,A9270,59651021430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,40.74 ,28.52 ,Aetna,"AETNA",18.33,45,percent of total billed charges,999999999,0.03087,28.518,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE (ANAPHYLAXIS) 30 MG/30ML INJ SOLN",0250,J0171,42023016801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,15.00 ,10.50 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,10.5,fee schedule,"191% of Drug Fee Schedule"
"BENRALIZUMAB 30 MG/ML SC SOSY",0250,J0517,00310173030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,16965.54 ,11875.88 ,Aetna,"AETNA",315.63,191,fee schedule,999999999,169.47,11875.878,fee schedule,"191% of Drug Fee Schedule"
"BISACODYL EC 5 MG PO TBEC",0250,A9270,00904792760,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIVOLUMAB 240 MG/24ML IV SOLN",0250,J9299,00003373413,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,22369.54 ,15658.68 ,Aetna,"AETNA",59.38,191,fee schedule,999999999,29.55,15658.678,fee schedule,"191% of Drug Fee Schedule"
"ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN",0250,J0256,13533070501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1665.00 ,1165.50 ,Aetna,"AETNA",9.38,191,fee schedule,999999999,4.57,1165.5,fee schedule,"191% of Drug Fee Schedule"
"ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN",0250,J0256,13533070511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1665.00 ,1165.50 ,Aetna,"AETNA",9.38,191,fee schedule,999999999,4.57,1165.5,fee schedule,"191% of Drug Fee Schedule"
"LEUPROLIDE ACETATE 3.75 MG IM KIT",0250,J1950,00074364103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.75,ME,,4791.45 ,3354.02 ,Aetna,"AETNA",3010.39,191,fee schedule,999999999,1437.435,3354.015,fee schedule,"191% of Drug Fee Schedule"
"GEMCITABINE HCL 1 GM/10ML IV SOLN",0250,J9196,16729041903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,109.32 ,76.52 ,Aetna,"AETNA",8.10,191,fee schedule,999999999,3.69,76.524,fee schedule,"191% of Drug Fee Schedule"
"GEMCITABINE HCL 2 GM/20ML IV SOLN",0250,J9196,16729042605,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,213.24 ,149.27 ,Aetna,"AETNA",8.10,191,fee schedule,999999999,3.69,149.268,fee schedule,"191% of Drug Fee Schedule"
"BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG PO TABS",0250,A9270,61958250101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,776.33 ,543.43 ,Aetna,"AETNA",349.35,45,percent of total billed charges,999999999,0.03087,543.431,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUAIFENESIN 100 MG/5ML PO LIQD",0250,A9270,00121174405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,8.673,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUAIFENESIN 100 MG/5ML PO LIQD",0250,A9270,00121174400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.39 ,8.67 ,Aetna,"AETNA",5.58,45,percent of total billed charges,999999999,0.03087,8.673,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RABIES IMMUNE GLOBULIN 300 UNIT/2ML INJ SOLN",0250,90377,76125015002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,UN  ,,2186.80 ,1530.76 ,Aetna,"AETNA",984.06,45,percent of total billed charges,999999999,546.7,1530.76,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN SODIUM-DEXTROSE 1-4 GM/50ML-% IV SOLN",0250,J0689,00338350341,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,47.04 ,32.93 ,Aetna,"AETNA",2.37,191,fee schedule,999999999,1.21,32.928,fee schedule,"191% of Drug Fee Schedule"
"NAFCILLIN SODIUM 10 G IV SOLR",0250,,00781312695,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,623.65 ,436.56 ,Aetna,"AETNA",280.64,45,percent of total billed charges,999999999,187.095,436.555,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MAGNESIUM CHLORIDE 64 MG PO TBEC",0250,A9270,68585000575,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COLISTIMETHATE SODIUM (CBA) 150 MG INJ SOLR",0250,J0770,63323039306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,ME,,69.44 ,48.61 ,Aetna,"AETNA",24.52,191,fee schedule,999999999,12.28,48.608,fee schedule,"191% of Drug Fee Schedule"
"BACITRACIN ZINC 500 UNIT/GM EX OINT",0250,A9270,51672207501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,11.43 ,8.00 ,Aetna,"AETNA",5.14,45,percent of total billed charges,999999999,0.03087,8.001,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAPTOMYCIN 350 MG IV SOLR",0250,J0878,25021017915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,167.04 ,116.93 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.038,116.928,fee schedule,"191% of Drug Fee Schedule"
"BACLOFEN 5 MG PO TABS",0250,A9270,72888000901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TALC 4 G PL POWD",0250,,62327044444,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,840.00 ,588.00 ,Aetna,"AETNA",378.00,45,percent of total billed charges,999999999,252,588,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COCAINE HCL 40 MG/ML NA SOLN",0250,,64950036204,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,1049.50 ,734.65 ,Aetna,"AETNA",472.28,45,percent of total billed charges,999999999,314.85,734.65,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE HCL-NACL 4-0.9 MG/250ML-% IV SOLN",0250,,99999042399,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,63,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX SHAM",0250,A9270,00904734920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,54.52 ,38.16 ,Aetna,"AETNA",24.53,45,percent of total billed charges,999999999,0.03087,38.164,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BARICITINIB 2 MG PO TABS",0250,A9270,00002418230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,268.86 ,188.20 ,Aetna,"AETNA",120.99,45,percent of total billed charges,999999999,0.03087,188.202,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPOETIN ALFA-EPBX 2000 UNIT/ML INJ SOLN",0250,Q5105,00069130501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,109.10 ,76.37 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,76.37,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 2000 UNIT/ML INJ SOLN",0250,Q5105,00069130510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,109.10 ,76.37 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,76.37,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 3000 UNIT/ML INJ SOLN",0250,Q5105,00069130601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,163.66 ,114.56 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,114.562,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 3000 UNIT/ML INJ SOLN",0250,Q5105,00069130610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,163.66 ,114.56 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,114.562,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 4000 UNIT/ML INJ SOLN",0250,Q5105,00069130701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,218.21 ,152.75 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,152.747,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 4000 UNIT/ML INJ SOLN",0250,Q5105,00069130710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,218.21 ,152.75 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,152.747,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 10000 UNIT/ML INJ SOLN",0250,Q5105,00069130801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,545.53 ,381.87 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,381.871,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 10000 UNIT/ML INJ SOLN",0250,Q5105,00069130810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,545.53 ,381.87 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,381.871,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 40000 UNIT/ML INJ SOLN",0250,Q5105,00069130901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,1818.43 ,1272.90 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,1272.901,fee schedule,"191% of Drug Fee Schedule"
"EPOETIN ALFA-EPBX 40000 UNIT/ML INJ SOLN",0250,Q5105,00069130904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,1818.43 ,1272.90 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.73,1272.901,fee schedule,"191% of Drug Fee Schedule"
"DAUNORUBICIN HCL 20 MG/4ML IV SOLN",0250,J9150,00143955101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,384.53 ,269.17 ,Aetna,"AETNA",60.17,191,fee schedule,999999999,31.64,269.171,fee schedule,"191% of Drug Fee Schedule"
"DAUNORUBICIN HCL 20 MG/4ML IV SOLN",0250,J9150,00143955110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,384.53 ,269.17 ,Aetna,"AETNA",60.17,191,fee schedule,999999999,31.64,269.171,fee schedule,"191% of Drug Fee Schedule"
"DAUNORUBICIN HCL 50 MG/10ML IV SOLN",0250,J9150,00143955001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,900.00 ,630.00 ,Aetna,"AETNA",60.17,191,fee schedule,999999999,31.64,630,fee schedule,"191% of Drug Fee Schedule"
"COLESTIPOL HCL 1 G PO TABS",0250,A9270,00115521116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,11.46 ,8.02 ,Aetna,"AETNA",5.16,45,percent of total billed charges,999999999,0.03087,8.022,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/500ML-% IV SOLN",0250,J1644,00409315020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,31.50 ,22.05 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,22.05,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN (PORCINE) IN NACL 25000-0.45 UT/500ML-% IV SOLN",0250,J1644,00409315005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,31.50 ,22.05 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,22.05,fee schedule,"191% of Drug Fee Schedule"
"PETROLATUM 42 % EX OINT",0250,A9270,00536114397,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,32.90 ,23.03 ,Aetna,"AETNA",14.81,45,percent of total billed charges,999999999,0.03087,48.944,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PETROLATUM 42 % EX OINT",0250,A9270,00536114398,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,69.92 ,48.94 ,Aetna,"AETNA",31.46,45,percent of total billed charges,999999999,0.03087,48.944,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARISOPRODOL 350 MG PO TABS",0250,A9270,50228010901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CROTALIDAE IMMUNE FAB (EQUINE) IV SOLR",0250,J0841,66621079002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,30000.00 ,21000.00 ,Aetna,"AETNA",2000.32,191,fee schedule,999999999,912.076,21000,fee schedule,"191% of Drug Fee Schedule"
"CARFILZOMIB 10 MG IV SOLR",0250,J9047,76075010301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",90.11,191,fee schedule,999999999,44.03,1750,fee schedule,"191% of Drug Fee Schedule"
"CLONIDINE 0.1 MG/24HR TD PTWK",0250,A9270,00378087199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,66.52 ,46.56 ,Aetna,"AETNA",29.93,45,percent of total billed charges,999999999,0.03087,49.805,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE 0.1 MG/24HR TD PTWK",0250,A9270,00378087116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,71.15 ,49.81 ,Aetna,"AETNA",32.02,45,percent of total billed charges,999999999,0.03087,49.805,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE 0.2 MG/24HR TD PTWK",0250,A9270,00378087299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,82.56 ,57.79 ,Aetna,"AETNA",37.15,45,percent of total billed charges,999999999,0.03087,92.099,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE 0.2 MG/24HR TD PTWK",0250,A9270,00378087216,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,131.57 ,92.10 ,Aetna,"AETNA",59.21,45,percent of total billed charges,999999999,0.03087,92.099,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE 0.3 MG/24HR TD PTWK",0250,A9270,00378087399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,105.71 ,74.00 ,Aetna,"AETNA",47.57,45,percent of total billed charges,999999999,0.03087,115.136,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE 0.3 MG/24HR TD PTWK",0250,A9270,00378087316,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,164.48 ,115.14 ,Aetna,"AETNA",74.02,45,percent of total billed charges,999999999,0.03087,115.136,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEASLES-MUMPS-RUBELLA-VARICELL SC SUSR",0250,90710,00006417100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,125.72 ,88.00 ,Aetna,"AETNA",56.57,45,percent of total billed charges,999999999,22.715,88.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEASLES-MUMPS-RUBELLA-VARICELL SC SUSR",0250,90710,00006417101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,90.86 ,63.60 ,Aetna,"AETNA",40.89,45,percent of total billed charges,999999999,22.715,88.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN HCL 1 G IV SOLR",0250,J3370,67457034001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,13.45 ,9.42 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,9.415,fee schedule,"191% of Drug Fee Schedule"
"VANCOMYCIN HCL 1 G IV SOLR",0250,J3370,67457034000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,13.45 ,9.42 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,9.415,fee schedule,"191% of Drug Fee Schedule"
"VANCOMYCIN HCL 5 G IV SOLR",0250,J3370,67457034105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,79.80 ,55.86 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,55.86,fee schedule,"191% of Drug Fee Schedule"
"SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK",0250,A9270,00310110501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,GR,,28.86 ,20.20 ,Aetna,"AETNA",12.99,45,percent of total billed charges,999999999,0.03087,21.21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK",0250,A9270,00310110530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,GR,,30.30 ,21.21 ,Aetna,"AETNA",13.64,45,percent of total billed charges,999999999,0.03087,21.21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK",0250,A9270,00310111001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,GR,,14.43 ,10.10 ,Aetna,"AETNA",6.49,45,percent of total billed charges,999999999,0.03087,10.605,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 G PO PACK",0250,A9270,00310111030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,GR,,15.15 ,10.61 ,Aetna,"AETNA",6.82,45,percent of total billed charges,999999999,0.03087,10.605,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CANNABIDIOL 100 MG/ML PO SOLN",0250,A9270,70127010001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,3930.00 ,2751.00 ,Aetna,"AETNA",1768.50,45,percent of total billed charges,999999999,0.03087,2751,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CANNABIDIOL 100 MG/ML PO SOLN",0250,A9270,70127010010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,3930.00 ,2751.00 ,Aetna,"AETNA",1768.50,45,percent of total billed charges,999999999,0.03087,2751,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FISH OIL TRIGLYCERIDES 5 GM/50ML IV EMUL",0250,,63323020521,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,270.60 ,189.42 ,Aetna,"AETNA",121.77,45,percent of total billed charges,999999999,81.18,213.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FISH OIL TRIGLYCERIDES 5 GM/50ML IV EMUL",0250,,63323020550,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,304.50 ,213.15 ,Aetna,"AETNA",137.03,45,percent of total billed charges,999999999,81.18,213.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOGAMULIZUMAB-KPKC 20 MG/5ML IV SOLN",0250,,42747076101,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,11370.00 ,7959.00 ,Aetna,"AETNA",5116.50,45,percent of total billed charges,999999999,2842.5,7959,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LAMOTRIGINE 25 MG PO TABS",0250,A9270,00904700761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LAMOTRIGINE 100 MG PO TABS",0250,A9270,00904700861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTRIAXONE SODIUM-DEXTROSE 1-3.74 GM-%(50ML) IV SOLR",0250,J0696,00264315311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,102.00 ,71.40 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,71.4,fee schedule,"191% of Drug Fee Schedule"
"CEFTRIAXONE SODIUM-DEXTROSE 2-2.22 GM-%(50ML) IV SOLR",0250,J0696,00264315511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,136.00 ,95.20 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,95.2,fee schedule,"191% of Drug Fee Schedule"
"CEMIPLIMAB-RWLC 350 MG/7ML IV SOLN",0250,,61755000801,RC,,NDC,FACILITY,OUTPATIENT,7,ML,,29879.66 ,20915.76 ,Aetna,"AETNA",13445.85,45,percent of total billed charges,999999999,7469.915,20915.762,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN",0250,Q5107,55513020601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",51.09,191,fee schedule,999999999,24.33,1750,fee schedule,"191% of Drug Fee Schedule"
"BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN",0250,Q5107,55513020701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,6480.43 ,4536.30 ,Aetna,"AETNA",51.09,191,fee schedule,999999999,24.33,4536.301,fee schedule,"191% of Drug Fee Schedule"
"AMINOLEVULINIC ACID HCL 1.5 G PO SOLR",0250,A9270,59137023101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8367.00 ,5856.90 ,Aetna,"AETNA",3765.15,45,percent of total billed charges,999999999,0.03087,5856.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMALIZUMAB 150 MG/ML SC SOSY",0250,J2357,50242021501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,4139.10 ,2897.37 ,Aetna,"AETNA",70.31,191,fee schedule,999999999,38.65,2897.37,fee schedule,"191% of Drug Fee Schedule"
"TBO-FILGRASTIM 300 MCG/ML SC SOLN",0250,J1447,63459091853,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,409.28 ,286.50 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.39,286.496,fee schedule,"191% of Drug Fee Schedule"
"TBO-FILGRASTIM 300 MCG/ML SC SOLN",0250,J1447,63459091859,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,409.28 ,286.50 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.39,286.496,fee schedule,"191% of Drug Fee Schedule"
"PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY",0250,Q5111,70114010101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,12117.93 ,8482.55 ,Aetna,"AETNA",258.79,191,fee schedule,999999999,122.103,8482.551,fee schedule,"191% of Drug Fee Schedule"
"DEXMEDETOMIDINE HCL-DEXTROSE 200MCG/50ML -5% IV SOLN",0250,,44567060224,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,51.80 ,36.26 ,Aetna,"AETNA",23.31,45,percent of total billed charges,999999999,15.54,36.26,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXMEDETOMIDINE HCL-DEXTROSE 400MCG/100ML -5% IV SOLN",0250,,99999054099,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN",0250,J0613,44567062001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,59.85 ,41.90 ,Aetna,"AETNA",0.17,191,fee schedule,999999999,0.08,41.895,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE-NACL 1-0.675 GM/50ML-% IV SOLN",0250,J0613,44567062024,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,59.85 ,41.90 ,Aetna,"AETNA",0.17,191,fee schedule,999999999,0.08,41.895,fee schedule,"191% of Drug Fee Schedule"
"ABLYSINOL IA SOLN",0250,,54288010502,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,900,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ABLYSINOL IA SOLN",0250,,54288010515,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,900,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR",0250,,50242010501,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,52429.14 ,36700.40 ,Aetna,"AETNA",23593.11,45,percent of total billed charges,999999999,13107.285,36700.398,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML INJ SOLN",0250,J0780,00641613501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,12.19 ,8.53 ,Aetna,"AETNA",7.53,191,fee schedule,999999999,2.85,8.533,fee schedule,"191% of Drug Fee Schedule"
"PROCHLORPERAZINE EDISYLATE 10 MG/2ML INJ SOLN",0250,J0780,00641613525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,12.19 ,8.53 ,Aetna,"AETNA",7.53,191,fee schedule,999999999,2.85,8.533,fee schedule,"191% of Drug Fee Schedule"
"TREPROSTINIL 50 MG/20ML INJ SOLN",0250,J3285,00781342580,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,15598.92 ,10919.24 ,Aetna,"AETNA",104.19,191,fee schedule,999999999,55.2,10919.244,fee schedule,"191% of Drug Fee Schedule"
"TREPROSTINIL 50 MG/20ML INJ SOLN",0250,J3285,00703067601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8618.82 ,6033.17 ,Aetna,"AETNA",104.19,191,fee schedule,999999999,55.2,10919.244,fee schedule,"191% of Drug Fee Schedule"
"TREPROSTINIL 100 MG/20ML INJ SOLN",0250,J3285,66302010501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,22106.28 ,15474.40 ,Aetna,"AETNA",104.19,191,fee schedule,999999999,55.2,15474.396,fee schedule,"191% of Drug Fee Schedule"
"TREPROSTINIL 200 MG/20ML INJ SOLN",0250,J3285,00781343080,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,63217.32 ,44252.12 ,Aetna,"AETNA",104.19,191,fee schedule,999999999,55.2,44252.124,fee schedule,"191% of Drug Fee Schedule"
"DEXRAZOXANE HCL 500 MG IV SOLR",0250,J1190,00143924801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,821.22 ,574.85 ,Aetna,"AETNA",173.98,191,fee schedule,999999999,98.82,574.854,fee schedule,"191% of Drug Fee Schedule"
"PALIPERIDONE PALMITATE ER 234 MG/1.5ML IM SUSY",0250,J2426,50458056401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9165.27 ,6415.69 ,Aetna,"AETNA",27.27,191,fee schedule,999999999,13.28,6415.689,fee schedule,"191% of Drug Fee Schedule"
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY",0250,,00409490334,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,36.96 ,25.87 ,Aetna,"AETNA",16.63,45,percent of total billed charges,999999999,10.071,25.872,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY",0250,,00409490311,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,33.57 ,23.50 ,Aetna,"AETNA",15.11,45,percent of total billed charges,999999999,10.071,25.872,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY",0250,,00409132305,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,31.47 ,22.03 ,Aetna,"AETNA",14.16,45,percent of total billed charges,999999999,8.589,22.029,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY",0250,,00409132315,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,28.63 ,20.04 ,Aetna,"AETNA",12.88,45,percent of total billed charges,999999999,8.589,22.029,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPATITIS A-HEP B RECOMB VAC 720-20 ELU-MCG/ML IM SUSY",0250,90636,58160081552,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,112.80 ,78.96 ,Aetna,"AETNA",50.76,45,percent of total billed charges,999999999,28.2,78.96,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DENOSUMAB 60 MG/ML SC SOSY",0250,J0897,55513071001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,4850.94 ,3395.66 ,Aetna,"AETNA",48.11,191,fee schedule,999999999,22.51,3395.658,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN (PORCINE) IN NACL 2000-0.9 UNIT/L-% IV SOLN",0250,J1644,00338043304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,35.00 ,24.50 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.5,fee schedule,"191% of Drug Fee Schedule"
"ATEZOLIZUMAB 840 MG/14ML IV SOLN",0250,J9022,50242091801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,22187.80 ,15531.46 ,Aetna,"AETNA",160.33,191,fee schedule,999999999,82.07,15531.46,fee schedule,"191% of Drug Fee Schedule"
"AMPHOTERICIN B 50 MG IV SOLR",0250,J0285,39822105505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,200.82 ,140.57 ,Aetna,"AETNA",73.67,191,fee schedule,999999999,9.536,140.574,fee schedule,"191% of Drug Fee Schedule"
"FAT EMUL FISH OIL/PLANT BASED 20 % IV EMUL",0250,,63323082000,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,120.60 ,84.42 ,Aetna,"AETNA",54.27,45,percent of total billed charges,999999999,36.18,84.42,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAT EMUL FISH OIL/PLANT BASED 20 % IV EMUL",0250,,63323082001,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,120.60 ,84.42 ,Aetna,"AETNA",54.27,45,percent of total billed charges,999999999,36.18,84.42,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUCONAZOLE 10 MG/ML PO SUSR",0250,A9270,16714069501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.60 ,8.82 ,Aetna,"AETNA",5.67,45,percent of total billed charges,999999999,0.03087,8.82,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROMOSOZUMAB-AQQG 105 MG/1.17ML SC SOSY",0250,J3111,55513088002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,7275.33 ,5092.73 ,Aetna,"AETNA",20.42,191,fee schedule,999999999,9.8,5092.731,fee schedule,"191% of Drug Fee Schedule"
"TRASTUZUMAB-ANNS 420 MG IV SOLR",0250,Q5117,55513013201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,7658.91 ,5361.24 ,Aetna,"AETNA",33.77,191,fee schedule,999999999,13.39,5361.237,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN",0250,J0613,44567062101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,108.00 ,75.60 ,Aetna,"AETNA",0.17,191,fee schedule,999999999,0.08,75.6,fee schedule,"191% of Drug Fee Schedule"
"CALCIUM GLUCONATE-NACL 2-0.675 GM/100ML-% IV SOLN",0250,J0613,44567062124,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,108.00 ,75.60 ,Aetna,"AETNA",0.17,191,fee schedule,999999999,0.08,75.6,fee schedule,"191% of Drug Fee Schedule"
"AMLODIPINE BENZOATE 1 MG/ML PO SUSP",0250,A9270,52652500101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,41.67 ,29.17 ,Aetna,"AETNA",18.75,45,percent of total billed charges,999999999,0.03087,29.169,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SELENIOUS ACID 60 MCG/ML IV SOLN",0250,,00517656005,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,1050.80 ,735.56 ,Aetna,"AETNA",472.86,45,percent of total billed charges,999999999,315.24,735.56,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN",0250,A9270,42571038273,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,7.231,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN",0250,A9270,99999072799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,10.33 ,7.23 ,Aetna,"AETNA",4.65,45,percent of total billed charges,999999999,0.03087,7.231,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002771401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,107.89 ,75.52 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,"191% of Drug Fee Schedule"
"INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002771459,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,"191% of Drug Fee Schedule"
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002822201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,107.89 ,75.52 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,"191% of Drug Fee Schedule"
"INSULIN LISPRO (1 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002822259,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,"191% of Drug Fee Schedule"
"CALASPARGASE PEGOL-MKNL 3750 UNIT/5ML IV SOLN",0250,J9118,72694051501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,81219.96 ,56853.97 ,Aetna,"AETNA",139.20,191,fee schedule,999999999,72.87,56853.972,fee schedule,"191% of Drug Fee Schedule"
"SODIUM CHLORIDE (PF) 0.9 % INJ SOLN",0250,,00409488810,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE (PF) 0.9 % INJ SOLN",0250,,00409488803,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE (PF) 0.9 % INJ SOLN",0250,,63323018603,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE (PF) 0.9 % INJ SOLN",0250,,63323018620,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LANSOPRAZOLE 30 MG PO TBDD",0250,A9270,65862089678,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.73 ,21.51 ,Aetna,"AETNA",13.83,45,percent of total billed charges,999999999,0.03087,21.511,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LANSOPRAZOLE 30 MG PO TBDD",0250,A9270,65862089610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.73 ,21.51 ,Aetna,"AETNA",13.83,45,percent of total billed charges,999999999,0.03087,21.511,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DUPILUMAB 200 MG/1.14ML SC SOSY",0250,J3590,00024591801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,5311.74 ,3718.22 ,Aetna,"AETNA",2390.28,45,percent of total billed charges,999999999,1593.522,3718.218,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEASLES, MUMPS & RUBELLA VAC INJ SOLR",0250,90707,00006468100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,68.95 ,48.27 ,Aetna,"AETNA",31.03,45,percent of total billed charges,999999999,17.2375,48.265,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEASLES, MUMPS & RUBELLA VAC INJ SOLR",0250,90707,00006468101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,68.95 ,48.27 ,Aetna,"AETNA",31.03,45,percent of total billed charges,999999999,17.2375,48.265,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRASTUZUMAB-DKST 150 MG IV SOLR",0250,Q5114,67457099115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",119.60,191,fee schedule,999999999,40.04,1750,fee schedule,"191% of Drug Fee Schedule"
"TRASTUZUMAB-DKST 420 MG IV SOLR",0250,Q5114,67457084744,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5149.05 ,3604.34 ,Aetna,"AETNA",119.60,191,fee schedule,999999999,40.04,3604.335,fee schedule,"191% of Drug Fee Schedule"
"ERGOCALCIFEROL 200 MCG/ML PO SOLN",0250,A9270,75834001060,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY",0250,,76329301505,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,66.64 ,46.65 ,Aetna,"AETNA",29.99,45,percent of total billed charges,999999999,7.233,46.648,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY",0250,,25021067376,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,24.11 ,16.88 ,Aetna,"AETNA",10.85,45,percent of total billed charges,999999999,7.233,46.648,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D3 (CHOLECALCIFEROL) 25 MCG (1000 UT) PO TABS",0250,A9270,20555003300,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D 10 MCG/ML PO LIQD",0250,A9270,54838000650,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D 10 MCG/ML PO LIQD",0250,A9270,99999011399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BARICITINIB 1 MG PO TABS",0250,A9270,00002473230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,537.73 ,376.41 ,Aetna,"AETNA",241.98,45,percent of total billed charges,999999999,0.03087,376.411,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRASTUZUMAB-ANNS 150 MG IV SOLR",0250,Q5117,55513014101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",33.77,191,fee schedule,999999999,13.39,2100,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM 1 G INJ SOLR",0250,J0690,44567070725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,7.30 ,5.11 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,5.11,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM 10 G INJ SOLR",0250,J0690,00143926110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,55.40 ,38.78 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,38.78,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM 10 G INJ SOLR",0250,J0690,00143926101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,55.40 ,38.78 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,38.78,fee schedule,"191% of Drug Fee Schedule"
"DORZOLAMIDE HCL 2 % OP SOLN",0250,A9270,24208048510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,189.66 ,132.76 ,Aetna,"AETNA",85.35,45,percent of total billed charges,999999999,0.03087,132.762,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MOMETASONE FURO-FORMOTEROL FUM 50-5 MCG/ACT INH AERO",0250,A9270,78206012501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,556.61 ,389.63 ,Aetna,"AETNA",250.47,45,percent of total billed charges,999999999,0.03087,389.627,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN",0250,Q5118,00069031501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,1814.06 ,1269.84 ,Aetna,"AETNA",39.65,191,fee schedule,999999999,17.43,1269.842,fee schedule,"191% of Drug Fee Schedule"
"BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN",0250,Q5118,00069034201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4353.79 ,3047.65 ,Aetna,"AETNA",39.65,191,fee schedule,999999999,17.43,3047.653,fee schedule,"191% of Drug Fee Schedule"
"PEGFILGRASTIM-BMEZ 6 MG/0.6ML SC SOSY",0250,,61314086601,RC,,NDC,FACILITY,OUTPATIENT,0.6,ML,,11393.85 ,7975.70 ,Aetna,"AETNA",5127.23,45,percent of total billed charges,999999999,2848.4625,7975.695,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LUSPATERCEPT-AAMT 25 MG SC SOLR",0250,J0896,59572071101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,11583.51 ,8108.46 ,Aetna,"AETNA",76.36,191,fee schedule,999999999,37.93,8108.457,fee schedule,"191% of Drug Fee Schedule"
"LUSPATERCEPT-AAMT 75 MG SC SOLR",0250,J0896,59572077501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,34750.44 ,24325.31 ,Aetna,"AETNA",76.36,191,fee schedule,999999999,37.93,24325.308,fee schedule,"191% of Drug Fee Schedule"
"CRIZANLIZUMAB-TMCA 100 MG/10ML IV SOLN",0250,,00078088361,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7330.86 ,5131.60 ,Aetna,"AETNA",3298.89,45,percent of total billed charges,999999999,1832.715,5131.602,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR",0250,,51144002001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,8262.00 ,5783.40 ,Aetna,"AETNA",3717.90,45,percent of total billed charges,999999999,2065.5,5783.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR",0250,,51144003001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,12393.00 ,8675.10 ,Aetna,"AETNA",5576.85,45,percent of total billed charges,999999999,3098.25,8675.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERAZOSIN HCL 1 MG PO CAPS",0250,A9270,50268076411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERAZOSIN HCL 1 MG PO CAPS",0250,A9270,50268076415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.23 ,3.66 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERAZOSIN HCL 2 MG PO CAPS",0250,A9270,23155073601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TERAZOSIN HCL 5 MG PO CAPS",0250,A9270,50268076615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRASTUZUMAB-PKRB 420 MG IV SOLR",0250,Q5113,63459030547,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11398.11 ,7978.68 ,Aetna,"AETNA",106.58,191,fee schedule,999999999,20.18,7978.677,fee schedule,"191% of Drug Fee Schedule"
"TRASTUZUMAB-QYYP 420 MG IV SOLR",0250,Q5116,00069030601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,7068.24 ,4947.77 ,Aetna,"AETNA",24.39,191,fee schedule,999999999,7.73,4947.768,fee schedule,"191% of Drug Fee Schedule"
"TRASTUZUMAB-PKRB 150 MG IV SOLR",0250,Q5113,63459030343,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4070.76 ,2849.53 ,Aetna,"AETNA",106.58,191,fee schedule,999999999,20.18,2849.532,fee schedule,"191% of Drug Fee Schedule"
"DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR",0250,J9155,55566840301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2306.15 ,1614.31 ,Aetna,"AETNA",8.31,191,fee schedule,999999999,4.08,1614.305,fee schedule,"191% of Drug Fee Schedule"
"SODIUM HYPOCHLORITE 0.25 % EX SOLN",0250,A9270,99999576599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CENOBAMATE 50 MG PO TABS",0250,A9270,71699005030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,54.94 ,38.46 ,Aetna,"AETNA",24.72,45,percent of total billed charges,999999999,0.03087,38.458,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CENOBAMATE 100 MG PO TABS",0250,A9270,71699010030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,27.47 ,19.23 ,Aetna,"AETNA",12.36,45,percent of total billed charges,999999999,0.03087,19.229,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPTINEZUMAB-JJMR 100 MG/ML IV SOLN",0250,J3032,67386013051,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5283.03 ,3698.12 ,Aetna,"AETNA",34.48,191,fee schedule,999999999,16.41,3698.121,fee schedule,"191% of Drug Fee Schedule"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN",0250,,00409729501,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,86.67 ,60.67 ,Aetna,"AETNA",39.00,45,percent of total billed charges,999999999,24.543,60.669,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN",0250,,00409729511,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,81.81 ,57.27 ,Aetna,"AETNA",36.81,45,percent of total billed charges,999999999,24.543,60.669,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISATUXIMAB-IRFC 500 MG/25ML IV SOLN",0250,,00024065601,RC,,NDC,FACILITY,OUTPATIENT,25,ML,,11538.90 ,8077.23 ,Aetna,"AETNA",5192.51,45,percent of total billed charges,999999999,2884.725,8077.23,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL ER 180 MG PO TBCR",0250,A9270,51079089901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.03 ,9.12 ,Aetna,"AETNA",5.86,45,percent of total billed charges,999999999,0.03087,9.121,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL ER 180 MG PO TBCR",0250,A9270,51079089920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.96 ,9.07 ,Aetna,"AETNA",5.83,45,percent of total billed charges,999999999,0.03087,9.121,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN ER 75 MG PO CPCR",0250,A9270,31722056560,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAMADOL HCL 50 MG PO TABS",0250,A9270,00904717961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYTOMEGALOVIRUS IMMUNE GLOB IV INJ",0250,J0850,44206053211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4392.75 ,3074.93 ,Aetna,"AETNA",3453.70,191,fee schedule,999999999,1317.825,3453.7002,fee schedule,"191% of Drug Fee Schedule"
"VITAMIN A 3 MG (10000 UT) PO CAPS",0250,A9270,00904208560,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN A 15 MG/ML IM SOLN",0250,,61703041807,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,1534.56 ,1074.19 ,Aetna,"AETNA",690.55,45,percent of total billed charges,999999999,460.368,1074.192,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE (PERIANAL) 2.5 % EX CREA",0250,A9270,69315031228,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,41.36 ,28.95 ,Aetna,"AETNA",18.61,45,percent of total billed charges,999999999,0.03087,28.952,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAMOXINE HCL (PERIANAL) 1 % EX FOAM",0250,A9270,51862018015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,228.78 ,160.15 ,Aetna,"AETNA",102.95,45,percent of total billed charges,999999999,0.03087,160.146,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIMODIPINE 6 MG/ML PO SOLN",0250,A9270,24338026010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,258.96 ,181.27 ,Aetna,"AETNA",116.53,45,percent of total billed charges,999999999,0.03087,181.272,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIMODIPINE 6 MG/ML PO SOLN",0250,A9270,24338026012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,258.96 ,181.27 ,Aetna,"AETNA",116.53,45,percent of total billed charges,999999999,0.03087,181.272,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR",0250,J9317,55135013201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,7184.19 ,5028.93 ,Aetna,"AETNA",65.13,191,fee schedule,999999999,32.04,5028.933,fee schedule,"191% of Drug Fee Schedule"
"INFLIXIMAB-AXXQ 100 MG IV SOLR",0250,Q5121,55513067001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2370.40 ,1659.28 ,Aetna,"AETNA",46.55,191,fee schedule,999999999,25.28,1659.28,fee schedule,"191% of Drug Fee Schedule"
"BRILLIANT BLUE G 0.025 % IO SOSY",0250,,68803072225,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,840.00 ,588.00 ,Aetna,"AETNA",378.00,45,percent of total billed charges,999999999,252,588,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRILLIANT BLUE G 0.025 % IO SOSY",0250,,68803072205,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,840.00 ,588.00 ,Aetna,"AETNA",378.00,45,percent of total billed charges,999999999,252,588,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARATUMUMAB-HYALURONIDASE-FIHJ 1800-30000 MG-UT/15ML SC SOLN",0250,,57894050301,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,27115.61 ,18980.93 ,Aetna,"AETNA",12202.02,45,percent of total billed charges,999999999,6778.9025,18980.927,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC HIGH-DOSE QUAD 0.7 ML IM SUSY",0250,90662,49281012365,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.7,ML,,81.90 ,57.33 ,Aetna,"AETNA",36.86,45,percent of total billed charges,999999999,20.475,57.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC HIGH-DOSE QUAD 0.7 ML IM SUSY",0250,90662,49281012388,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.7,ML,,81.90 ,57.33 ,Aetna,"AETNA",36.86,45,percent of total billed charges,999999999,20.475,57.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METFORMIN HCL 850 MG PO TABS",0250,A9270,00904716361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INEBILIZUMAB-CDON 100 MG/10ML IV SOLN",0250,J1823,75987015001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,137095.29 ,95966.70 ,Aetna,"AETNA",904.40,191,fee schedule,999999999,462.87,95966.703,fee schedule,"191% of Drug Fee Schedule"
"INEBILIZUMAB-CDON 100 MG/10ML IV SOLN",0250,J1823,75987015003,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,137095.29 ,95966.70 ,Aetna,"AETNA",904.40,191,fee schedule,999999999,462.87,95966.703,fee schedule,"191% of Drug Fee Schedule"
"LURBINECTEDIN 4 MG IV SOLR",0250,,68727071201,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,23759.37 ,16631.56 ,Aetna,"AETNA",10691.72,45,percent of total billed charges,999999999,5939.8425,16631.559,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PERTUZ-TRASTUZ-HYALURON-ZZXF 60-60-2000 MG-MG-U/ML SC SOLN",0250,J9316,50242026001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,26075.91 ,18253.14 ,Aetna,"AETNA",124.76,191,fee schedule,999999999,67.051,18253.137,fee schedule,"191% of Drug Fee Schedule"
"PERTUZ-TRASTUZ-HYALURON-ZZXF 80-40-2000 MG-MG-U/ML SC SOLN",0250,J9316,50242024501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,39115.40 ,27380.78 ,Aetna,"AETNA",124.76,191,fee schedule,999999999,67.051,27380.78,fee schedule,"191% of Drug Fee Schedule"
"POLY-VI-SOL/IRON 11 MG/ML PO SOLN",0250,A9270,99999001399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLY-VI-SOL/IRON 11 MG/ML PO SOLN",0250,A9270,00087040501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIZANIDINE HCL 4 MG PO TABS",0250,A9270,00904641861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN",0250,,00517930501,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,128.98 ,90.29 ,Aetna,"AETNA",58.04,45,percent of total billed charges,999999999,38.694,90.286,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN",0250,,00517930525,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,128.98 ,90.29 ,Aetna,"AETNA",58.04,45,percent of total billed charges,999999999,38.694,90.286,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPHOSPHAMIDE 1 GM/5ML IV SOLN",0250,J9073,50742052005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1329.65 ,930.76 ,Aetna,"AETNA",1.87,191,fee schedule,999999999,1.06,930.755,fee schedule,"191% of Drug Fee Schedule"
"TAFASITAMAB-CXIX 200 MG IV SOLR",0250,J9349,73535020801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,3969.69 ,2778.78 ,Aetna,"AETNA",25.94,191,fee schedule,999999999,12.97,2778.783,fee schedule,"191% of Drug Fee Schedule"
"LOSARTAN POTASSIUM 25 MG PO TABS",0250,A9270,00904704761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOSARTAN POTASSIUM 50 MG PO TABS",0250,A9270,00904704861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FOSFOMYCIN TROMETHAMINE 3 G PO PACK",0250,,70700026894,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,317.58 ,222.31 ,Aetna,"AETNA",142.91,45,percent of total billed charges,999999999,95.274,222.306,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN",0250,J1265,00338100502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,49.00 ,34.30 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.63,34.3,fee schedule,"191% of Drug Fee Schedule"
"DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN",0250,J1265,00338100702,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,61.25 ,42.88 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.63,42.875,fee schedule,"191% of Drug Fee Schedule"
"DOXYLAMINE SUCCINATE (SLEEP) 25 MG PO TABS",0250,A9270,70000056701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLATUZUMAB VEDOTIN-PIIQ 30 MG IV SOLR",0250,,50242010301,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,11234.82 ,7864.37 ,Aetna,"AETNA",5055.67,45,percent of total billed charges,999999999,3370.446,7864.374,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERAVACYCLINE DIHYDROCHLORIDE 100 MG IV SOLR",0250,J0122,71773010012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,657.49 ,460.24 ,Aetna,"AETNA",2.12,191,fee schedule,999999999,1.06,460.243,fee schedule,"191% of Drug Fee Schedule"
"ERAVACYCLINE DIHYDROCHLORIDE 100 MG IV SOLR",0250,J0122,71773010005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,609.68 ,426.78 ,Aetna,"AETNA",2.12,191,fee schedule,999999999,1.06,460.243,fee schedule,"191% of Drug Fee Schedule"
"LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN",0250,J2001,00338040903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,24.50 ,17.15 ,Aetna,"AETNA",0.06,191,fee schedule,999999999,0.027,17.15,fee schedule,"191% of Drug Fee Schedule"
"SODIUM NITROPRUSSIDE 25 MG/ML IV SOLN",0250,,70436002880,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,62.86 ,44.00 ,Aetna,"AETNA",28.29,45,percent of total billed charges,999999999,18.858,44.002,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RAVULIZUMAB-CWVZ 300 MG/3ML IV SOLN",0250,J1303,25682002501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,19212.00 ,13448.40 ,Aetna,"AETNA",423.54,191,fee schedule,999999999,221.67,13448.4,fee schedule,"191% of Drug Fee Schedule"
"RAVULIZUMAB-CWVZ 1100 MG/11ML IV SOLN",0250,J1303,25682002801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,70443.98 ,49310.79 ,Aetna,"AETNA",423.54,191,fee schedule,999999999,221.67,49310.786,fee schedule,"191% of Drug Fee Schedule"
"DICLOFENAC SODIUM 1 % EX GEL",0250,,00536129434,RC,,NDC,FACILITY,OUTPATIENT,50,GR,,61.95 ,43.37 ,Aetna,"AETNA",27.88,45,percent of total billed charges,999999999,18.585,43.365,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE BACTERIOSTATIC 0.9 % INJ SOLN",0250,,00409196607,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,6.00 ,4.20 ,Aetna,"AETNA",2.70,45,percent of total billed charges,999999999,1.656,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE BACTERIOSTATIC 0.9 % INJ SOLN",0250,,00409196602,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,5.52 ,3.86 ,Aetna,"AETNA",2.48,45,percent of total billed charges,999999999,1.656,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEGFILGRASTIM-APGF 6 MG/0.6ML SC SOSY",0250,Q5122,00069032401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,11392.32 ,7974.62 ,Aetna,"AETNA",125.12,191,fee schedule,999999999,62.377,7974.624,fee schedule,"191% of Drug Fee Schedule"
"ATOVAQUONE 750 MG/5ML PO SUSP",0250,A9270,60687053478,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,178.08 ,124.66 ,Aetna,"AETNA",80.14,45,percent of total billed charges,999999999,0.03087,124.656,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LUGOLS STRONG IODINE 5-10 % EX SOLN",0250,,99999070599,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,58.10 ,40.67 ,Aetna,"AETNA",26.15,45,percent of total billed charges,999999999,17.43,40.67,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACTERIOSTATIC WATER(BENZ ALC) INJ SOLN",0250,,00409397703,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,10.92 ,7.64 ,Aetna,"AETNA",4.91,45,percent of total billed charges,999999999,3.276,7.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CABOTEGRAVIR & RILPIVIRINE ER 600 & 900 MG/3ML IM SUER",0250,J0741,49702024015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,19502.95 ,13652.07 ,Aetna,"AETNA",43.20,191,fee schedule,999999999,21.06,13652.065,fee schedule,"191% of Drug Fee Schedule"
"VIBEGRON 75 MG PO TABS",0250,A9270,73336007530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,81.50 ,57.05 ,Aetna,"AETNA",36.68,45,percent of total billed charges,999999999,0.03087,57.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRASTUZUMAB-QYYP 150 MG IV SOLR",0250,Q5116,00069030801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",24.39,191,fee schedule,999999999,7.73,1750,fee schedule,"191% of Drug Fee Schedule"
"PONARIS NA SOLN",0250,A9270,10592000101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,ML,,78.84 ,55.19 ,Aetna,"AETNA",35.48,45,percent of total billed charges,999999999,0.03087,55.188,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EVINACUMAB-DGNB 345 MG/2.3ML IV SOLN",0250,J1305,61755001301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,33637.50 ,23546.25 ,Aetna,"AETNA",342.16,191,fee schedule,999999999,175.78,23546.25,fee schedule,"191% of Drug Fee Schedule"
"EVINACUMAB-DGNB 1200 MG/8ML IV SOLN",0250,J1305,61755001001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,117000.00 ,81900.00 ,Aetna,"AETNA",342.16,191,fee schedule,999999999,175.78,81900,fee schedule,"191% of Drug Fee Schedule"
"NAPHAZOLINE-PHENIRAMINE 0.027-0.315 % OP SOLN",0250,A9270,10119002090,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,47.99 ,33.59 ,Aetna,"AETNA",21.60,45,percent of total billed charges,999999999,0.03087,33.593,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESMOPRESSIN ACETATE PF 4 MCG/ML INJ SOLN",0250,J2597,43598093109,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,52.56 ,36.79 ,Aetna,"AETNA",11.98,191,fee schedule,999999999,6.15,36.792,fee schedule,"191% of Drug Fee Schedule"
"DESMOPRESSIN ACETATE PF 4 MCG/ML INJ SOLN",0250,J2597,43598093111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,52.56 ,36.79 ,Aetna,"AETNA",11.98,191,fee schedule,999999999,6.15,36.792,fee schedule,"191% of Drug Fee Schedule"
"EPINEPHRINE-DEXTROSE 100-5 MCG/10ML-% IV SOSY",0250,J0171,70092161746,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,50.82 ,35.57 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,35.574,fee schedule,"191% of Drug Fee Schedule"
"POLY-VITE PEDIATRIC PO SOLN",0250,A9270,99999019199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLY-VITE PEDIATRIC PO SOLN",0250,A9270,00087040203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN E 180 MG (400 UNIT) PO CAPS",0250,A9270,77333095110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN E 180 MG (400 UNIT) PO CAPS",0250,A9270,77333095125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETIC ACID 3 % SOLN",0250,,51552005106,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,105.00 ,73.50 ,Aetna,"AETNA",47.25,45,percent of total billed charges,999999999,31.5,73.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MYCOPHENOLATE MOFETIL 250 MG PO CAPS",0250,J7517,00904707461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.38,191,fee schedule,999999999,0.188,3.5,fee schedule,"191% of Drug Fee Schedule"
"DOSTARLIMAB-GXLY 500 MG/10ML IV SOLN",0250,J9272,00173089803,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,33879.93 ,23715.95 ,Aetna,"AETNA",444.17,191,fee schedule,999999999,220.75,23715.951,fee schedule,"191% of Drug Fee Schedule"
"LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR",0250,J9359,79952011001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.075,ME,,78900.03 ,55230.02 ,Aetna,"AETNA",382.94,191,fee schedule,999999999,188.98,55230.021,fee schedule,"191% of Drug Fee Schedule"
"AMIVANTAMAB-VMJW 350 MG/7ML IV SOLN",0250,J9061,57894050101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,10007.95 ,7005.57 ,Aetna,"AETNA",38.18,191,fee schedule,999999999,18.9,7005.565,fee schedule,"191% of Drug Fee Schedule"
"SENNOSIDES 8.8 MG/5ML PO SYRP",0250,A9270,57237030124,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG PO TABS",0250,A9270,00024159601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.34 ,9.34 ,Aetna,"AETNA",6.00,45,percent of total billed charges,999999999,0.03087,9.338,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPARAGINASE ERWINIA CHRY-RYWN 10 MG/0.5ML IM SOLN",0250,J9021,68727090001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,14434.94 ,10104.46 ,Aetna,"AETNA",97.79,191,fee schedule,999999999,46.53,10104.458,fee schedule,"191% of Drug Fee Schedule"
"CASTOR OIL OIL",0250,A9270,00395051592,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,27.67 ,19.37 ,Aetna,"AETNA",12.45,45,percent of total billed charges,999999999,0.03087,19.369,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY",0250,90677,00005200002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,1106.90 ,774.83 ,Aetna,"AETNA",498.11,45,percent of total billed charges,999999999,268.3275,774.83,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY",0250,90677,00005200010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,1073.31 ,751.32 ,Aetna,"AETNA",482.99,45,percent of total billed charges,999999999,268.3275,774.83,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN",0250,,00517930201,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,106.40 ,74.48 ,Aetna,"AETNA",47.88,45,percent of total billed charges,999999999,31.92,74.48,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN",0250,,00517930225,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,106.40 ,74.48 ,Aetna,"AETNA",47.88,45,percent of total billed charges,999999999,31.92,74.48,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRANTEL PAMOATE 144 (50 BASE) MG/ML PO SUSP",0250,A9270,10956061801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,0.03087,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL",0250,,00338051909,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,87.00 ,60.90 ,Aetna,"AETNA",39.15,45,percent of total billed charges,999999999,16.65,60.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL",0250,,65219053550,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,55.50 ,38.85 ,Aetna,"AETNA",24.98,45,percent of total billed charges,999999999,16.65,60.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMANTADINE HCL 50 MG/5ML PO SOLN",0250,,00121064616,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MENING ACY&W-135 TETANUS CONJ IM SOLN",0250,90619,49281059005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,639.92 ,447.94 ,Aetna,"AETNA",287.96,45,percent of total billed charges,999999999,155.355,447.944,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MENING ACY&W-135 TETANUS CONJ IM SOLN",0250,90619,49281059058,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,621.42 ,434.99 ,Aetna,"AETNA",279.64,45,percent of total billed charges,999999999,155.355,447.944,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN E 450 MG (1000 UT) PO CAPS",0250,A9270,00904027760,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY",0250,J1670,13533063402,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,UN  ,,2500.00 ,1750.00 ,Aetna,"AETNA",1105.47,191,fee schedule,999999999,537.77,1750,fee schedule,"191% of Drug Fee Schedule"
"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5ML IM SOSY",0250,90371,13533063603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,450.24 ,315.17 ,Aetna,"AETNA",202.61,45,percent of total billed charges,999999999,112.56,315.168,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPATITIS B IMMUNE GLOBULIN 312 UNIT/ML IM SOLN",0250,90371,59730420301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,280.52 ,196.36 ,Aetna,"AETNA",126.23,45,percent of total billed charges,999999999,70.13,196.364,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THYROTROPIN ALFA 0.9 MG IM SOLR",0250,J3240,58468003002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.9,ME,,5931.72 ,4152.20 ,Aetna,"AETNA",3862.73,191,fee schedule,999999999,1779.516,4152.204,fee schedule,"191% of Drug Fee Schedule"
"THYROTROPIN ALFA 0.9 MG IM SOLR",0250,J3240,58468003001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.9,ME,,5931.72 ,4152.20 ,Aetna,"AETNA",3862.73,191,fee schedule,999999999,1779.516,4152.204,fee schedule,"191% of Drug Fee Schedule"
"VITAMIN E 6.75 MG/0.3ML PO SOLN",0250,A9270,39328001030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PIMOZIDE 1 MG PO TABS",0250,,57844015101,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.16 ,9.21 ,Aetna,"AETNA",5.92,45,percent of total billed charges,999999999,3.948,9.212,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIVOLUMAB 120 MG/12ML IV SOLN",0250,J9299,00003375614,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,11184.73 ,7829.31 ,Aetna,"AETNA",59.38,191,fee schedule,999999999,29.55,7829.311,fee schedule,"191% of Drug Fee Schedule"
"SODIUM THIOSULFATE 250 MG/ML IV SOLN",0250,,60267070550,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,582.00 ,407.40 ,Aetna,"AETNA",261.90,45,percent of total billed charges,999999999,174.6,407.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUMATRIPTAN SUCCINATE 25 MG PO TABS",0250,A9270,63304009711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUMATRIPTAN SUCCINATE 50 MG PO TABS",0250,A9270,63304009819,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,18.70 ,13.09 ,Aetna,"AETNA",8.42,45,percent of total billed charges,999999999,0.03087,13.09,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN",0250,J0153,55150019301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,99.90 ,69.93 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,69.93,fee schedule,"191% of Drug Fee Schedule"
"DICLOFENAC SODIUM 25 MG PO TBEC",0250,A9270,16571020310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.97 ,4.88 ,Aetna,"AETNA",3.14,45,percent of total billed charges,999999999,0.03087,4.879,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DICLOFENAC SODIUM 75 MG PO TBEC",0250,A9270,60687065801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DICLOFENAC SODIUM 75 MG PO TBEC",0250,A9270,60687065811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INCLISIRAN SODIUM 284 MG/1.5ML SC SOSY",0250,J1306,00078100060,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,10081.77 ,7057.24 ,Aetna,"AETNA",23.15,191,fee schedule,999999999,12.02,7057.239,fee schedule,"191% of Drug Fee Schedule"
"EFGARTIGIMOD ALFA-FCAB 400 MG/20ML IV SOLN",0250,J9332,73475304105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,18207.00 ,12744.90 ,Aetna,"AETNA",61.25,191,fee schedule,999999999,31.53,12744.9,fee schedule,"191% of Drug Fee Schedule"
"LEUCOVORIN CALCIUM 200 MG INJ SOLR",0250,J0640,63323071050,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,90.42 ,63.29 ,Aetna,"AETNA",9.82,191,fee schedule,999999999,4.02,105.588,fee schedule,"191% of Drug Fee Schedule"
"LEUCOVORIN CALCIUM 200 MG INJ SOLR",0250,J0640,25021081530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,150.84 ,105.59 ,Aetna,"AETNA",9.82,191,fee schedule,999999999,4.02,105.588,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM 2 G INJ SOLR",0250,J0690,60505623100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,41.36 ,28.95 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,28.952,fee schedule,"191% of Drug Fee Schedule"
"CEFAZOLIN SODIUM 2 G INJ SOLR",0250,J0690,60505623105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,29.70 ,20.79 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,28.952,fee schedule,"191% of Drug Fee Schedule"
"CHARCOAL ACTIVATED 25 G PO SUSR",0250,A9270,00574012225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,96.18 ,67.33 ,Aetna,"AETNA",43.28,45,percent of total billed charges,999999999,0.03087,67.326,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARUNAVIR 800 MG PO TABS",0250,A9270,68180034606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.53 ,11.57 ,Aetna,"AETNA",7.44,45,percent of total billed charges,999999999,0.03087,11.571,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY",0250,J0561,60793070110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,645.34 ,451.74 ,Aetna,"AETNA",42.02,191,fee schedule,999999999,16.73,451.738,fee schedule,"191% of Drug Fee Schedule"
"PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY",0250,J0561,60793070102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,586.67 ,410.67 ,Aetna,"AETNA",42.02,191,fee schedule,999999999,16.73,451.738,fee schedule,"191% of Drug Fee Schedule"
"HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML PO SOLN",0250,A9270,10702015016,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,34.692,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML PO SOLN",0250,A9270,99999046399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,34.692,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE BIT-HOMATROP MBR 5-1.5 MG/5ML PO SOLN",0250,A9270,64950034245,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,49.56 ,34.69 ,Aetna,"AETNA",22.30,45,percent of total billed charges,999999999,0.03087,34.692,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN LISPRO 100 UNIT/ML INJ SOLN",0250,J1815,00002753301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,"191% of Drug Fee Schedule"
"INSULIN ASPART 100 UNIT/ML INJ SOLN",0250,J1815,00169750111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,404.16 ,282.91 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,282.912,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 30 MG/0.3ML INJ SOSY",0250,J1650,71288043280,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11.50 ,8.05 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,8.05,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 30 MG/0.3ML INJ SOSY",0250,J1650,71288043281,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11.50 ,8.05 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,8.05,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 40 MG/0.4ML INJ SOSY",0250,J1650,71288043382,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.54 ,10.18 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,10.178,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 40 MG/0.4ML INJ SOSY",0250,J1650,71288043383,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.54 ,10.18 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,10.178,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 60 MG/0.6ML INJ SOSY",0250,J1650,71288043484,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,20.99 ,14.69 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,14.693,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 60 MG/0.6ML INJ SOSY",0250,J1650,71288043485,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,20.99 ,14.69 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,14.693,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 80 MG/0.8ML INJ SOSY",0250,J1650,71288043586,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,28.96 ,20.27 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,20.272,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 80 MG/0.8ML INJ SOSY",0250,J1650,71288043587,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,28.96 ,20.27 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,20.272,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 100 MG/ML INJ SOSY",0250,J1650,71288043688,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,36.23 ,25.36 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,25.361,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 100 MG/ML INJ SOSY",0250,J1650,71288043689,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,36.23 ,25.36 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,25.361,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 120 MG/0.8ML INJ SOSY",0250,J1650,71288043792,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,43.50 ,30.45 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,30.45,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 120 MG/0.8ML INJ SOSY",0250,J1650,71288043791,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,43.50 ,30.45 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,30.45,fee schedule,"191% of Drug Fee Schedule"
"ENOXAPARIN SODIUM 150 MG/ML INJ SOSY",0250,J1650,71288043896,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,63.63 ,44.54 ,Aetna,"AETNA",1.18,191,fee schedule,999999999,0.66,44.541,fee schedule,"191% of Drug Fee Schedule"
"SODIUM HYALURONATE 8.5 MG/0.85ML IO SOSY",0250,,08544636981,RC,,NDC,FACILITY,OUTPATIENT,0.85,ML,,406.44 ,284.51 ,Aetna,"AETNA",182.90,45,percent of total billed charges,999999999,121.932,284.508,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM HYALURONATE 11.9 MG/0.85ML IO SOSY",0250,,08544508541,RC,,NDC,FACILITY,OUTPATIENT,0.85,ML,,434.28 ,304.00 ,Aetna,"AETNA",195.43,45,percent of total billed charges,999999999,130.284,303.996,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM HYALURONATE 13.8 MG/0.6ML IO SOSY",0250,,08544508321,RC,,NDC,FACILITY,OUTPATIENT,0.6,ML,,831.60 ,582.12 ,Aetna,"AETNA",374.22,45,percent of total billed charges,999999999,249.48,582.12,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE 500 MG/100ML IV SOLN",0250,J1836,00409015201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,8.40 ,5.88 ,Aetna,"AETNA",0.06,191,fee schedule,999999999,0.02,5.88,fee schedule,"191% of Drug Fee Schedule"
"METRONIDAZOLE 500 MG/100ML IV SOLN",0250,J1836,00409015224,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,8.40 ,5.88 ,Aetna,"AETNA",0.06,191,fee schedule,999999999,0.02,5.88,fee schedule,"191% of Drug Fee Schedule"
"NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20ML IV SOLN",0250,J9298,00003712511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ML,,43431.78 ,30402.25 ,Aetna,"AETNA",357.17,191,fee schedule,999999999,180.64,30402.246,fee schedule,"191% of Drug Fee Schedule"
"LEVONORGESTREL 20 MCG/DAY IU IUD",0250,J7298,50419042301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,3470.37 ,2429.26 ,Aetna,"AETNA",2651.37,191,fee schedule,999999999,1041.111,2651.3665,fee schedule,"191% of Drug Fee Schedule"
"LEVONORGESTREL 20.1 MCG/DAY IU IUD",0250,J7297,00023585801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,52,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",2033.83,191,fee schedule,999999999,845.1,2100,fee schedule,"191% of Drug Fee Schedule"
"ESTROGENS CONJUGATED 0.625 MG/GM VA CREA",0250,,00046087221,RC,,NDC,FACILITY,OUTPATIENT,30,GR,,2095.20 ,1466.64 ,Aetna,"AETNA",942.84,45,percent of total billed charges,999999999,628.56,1466.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE SOD SUC (PF) 100 MG INJ SOLR",0250,J1720,00009001103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,56.28 ,39.40 ,Aetna,"AETNA",35.26,191,fee schedule,999999999,16.884,39.396,fee schedule,"191% of Drug Fee Schedule"
"HYDROCORTISONE SOD SUC (PF) 250 MG INJ SOLR",0250,J1720,00009001305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,104.76 ,73.33 ,Aetna,"AETNA",35.26,191,fee schedule,999999999,17.51,73.332,fee schedule,"191% of Drug Fee Schedule"
"HYDROCORTISONE SOD SUC (PF) 500 MG INJ SOLR",0250,J1720,00009001612,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,420.54 ,294.38 ,Aetna,"AETNA",35.26,191,fee schedule,999999999,17.51,294.378,fee schedule,"191% of Drug Fee Schedule"
"CHERRY PO SYRP",0250,A9270,00395266216,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,85.14 ,59.60 ,Aetna,"AETNA",38.31,45,percent of total billed charges,999999999,0.03087,59.598,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN 100 MG PR SUPP",0250,A9270,73702014071,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1425.00 ,997.50 ,Aetna,"AETNA",641.25,45,percent of total billed charges,999999999,0.03087,997.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRYPAN BLUE 0.06 % IO SOSY",0250,,68803061210,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,303.30 ,212.31 ,Aetna,"AETNA",136.49,45,percent of total billed charges,999999999,90.99,212.31,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RABIES VIRUS VACCINE, HDC IM SUSR",0250,90675,49281025251,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1615.25 ,1130.68 ,Aetna,"AETNA",726.86,45,percent of total billed charges,999999999,403.8125,1130.675,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPATITIS B VAC RECOMBINANT 20 MCG/ML INJ SUSY",0250,90746,58160082152,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,67.90 ,47.53 ,Aetna,"AETNA",30.56,45,percent of total billed charges,999999999,16.975,47.53,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FULVESTRANT 250 MG/5ML IM SOSY",0250,J9395,00310072010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",15.60,191,fee schedule,999999999,8.36,2100,fee schedule,"191% of Drug Fee Schedule"
"FULVESTRANT 250 MG/5ML IM SOSY",0250,J9395,25021046274,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,525.75 ,368.03 ,Aetna,"AETNA",15.60,191,fee schedule,999999999,8.36,2100,fee schedule,"191% of Drug Fee Schedule"
"HEPATITIS B VAC RECOMBINANT 10 MCG/0.5ML INJ SUSY",0250,90744,58160082052,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,12.95 ,9.07 ,Aetna,"AETNA",5.83,45,percent of total billed charges,999999999,3.2375,9.065,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLIPUDASE ALFA-RPCP 20 MG IV SOLR",0250,J0218,58468005001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,21854.52 ,15298.16 ,Aetna,"AETNA",719.27,191,fee schedule,999999999,376.965,15298.164,fee schedule,"191% of Drug Fee Schedule"
"ALENDRONATE SODIUM 10 MG PO TABS",0250,A9270,64980034001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"UMECLIDINIUM-VILANTEROL 62.5-25 MCG/ACT INH AEPB",0250,A9270,00173086906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.22 ,21.15 ,Aetna,"AETNA",13.60,45,percent of total billed charges,999999999,0.03087,36.106,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"UMECLIDINIUM-VILANTEROL 62.5-25 MCG/ACT INH AEPB",0250,A9270,00173086910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,51.58 ,36.11 ,Aetna,"AETNA",23.21,45,percent of total billed charges,999999999,0.03087,36.106,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUTICASONE-UMECLIDIN-VILANT 100-62.5-25 MCG/ACT INH AEPB",0250,A9270,00173088714,RC,HCPCS,NDC,FACILITY,OUTPATIENT,28,UN  ,,33.36 ,23.35 ,Aetna,"AETNA",15.01,45,percent of total billed charges,999999999,0.03087,23.352,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUTICASONE-UMECLIDIN-VILANT 200-62.5-25 MCG/ACT INH AEPB",0250,A9270,00173089314,RC,HCPCS,NDC,FACILITY,OUTPATIENT,28,UN  ,,33.36 ,23.35 ,Aetna,"AETNA",15.01,45,percent of total billed charges,999999999,0.03087,23.352,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CARB-CHOLECALCIFEROL 250-3.125 MG-MCG PO TABS",0250,A9270,20555002500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SOTALOL HCL 120 MG PO TABS",0250,A9270,60505015900,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TREMELIMUMAB-ACTL 25 MG/1.25ML IV SOLN",0250,J9347,00310450525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9712.95 ,6799.07 ,Aetna,"AETNA",259.28,191,fee schedule,999999999,136.093,6799.065,fee schedule,"191% of Drug Fee Schedule"
"TREMELIMUMAB-ACTL 300 MG/15ML IV SOLN",0250,J9347,00310453530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,116555.40 ,81588.78 ,Aetna,"AETNA",259.28,191,fee schedule,999999999,136.093,81588.78,fee schedule,"191% of Drug Fee Schedule"
"CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN",0250,A9270,60505082306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.7,ML,,200.71 ,140.50 ,Aetna,"AETNA",90.32,45,percent of total billed charges,999999999,0.03087,140.497,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BICALUTAMIDE 50 MG PO TABS",0250,A9270,47335048583,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 6.25 MG PO TABS",0250,A9270,00093013505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 6.25 MG PO TABS",0250,A9270,00904630161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 25 MG PO TABS",0250,A9270,00093729601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 25 MG PO TABS",0250,A9270,68462016501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 25 MG PO TABS",0250,A9270,43547025710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 12.5 MG PO TABS",0250,A9270,51079093101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 12.5 MG PO TABS",0250,A9270,51079093120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TECLISTAMAB-CQYV 30 MG/3ML SC SOLN",0250,J9380,57894044901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,4025.37 ,2817.76 ,Aetna,"AETNA",58.75,191,fee schedule,999999999,30.847,2817.759,fee schedule,"191% of Drug Fee Schedule"
"TECLISTAMAB-CQYV 153 MG/1.7ML SC SOLN",0250,J9380,57894045001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,20525.49 ,14367.84 ,Aetna,"AETNA",58.75,191,fee schedule,999999999,30.847,14367.843,fee schedule,"191% of Drug Fee Schedule"
"AZITHROMYCIN 200 MG/5ML PO SUSR",0250,,9999002299,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,52.71 ,36.90 ,Aetna,"AETNA",23.72,45,percent of total billed charges,999999999,5.997,36.897,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZITHROMYCIN 200 MG/5ML PO SUSR",0250,,42806014932,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,19.99 ,13.99 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,5.997,36.897,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"UBLITUXIMAB-XIIY 150 MG/6ML IV SOLN",0250,J2329,73150015006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,31298.09 ,21908.66 ,Aetna,"AETNA",128.41,191,fee schedule,999999999,65.56,21908.663,fee schedule,"191% of Drug Fee Schedule"
"GUAIFENESIN-DM 100-10 MG/5ML PO SYRP",0250,A9270,69339014905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.94 ,8.36 ,Aetna,"AETNA",5.37,45,percent of total billed charges,999999999,0.03087,8.505,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUAIFENESIN-DM 100-10 MG/5ML PO SYRP",0250,A9270,69339014919,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.15 ,8.51 ,Aetna,"AETNA",5.47,45,percent of total billed charges,999999999,0.03087,8.505,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYBUTYNIN CHLORIDE 5 MG/5ML PO SOLN",0250,A9270,54838051080,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LECANEMAB-IRMB 200 MG/2ML IV SOLN",0250,J0174,62856021201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1269.20 ,888.44 ,Aetna,"AETNA",2.56,191,fee schedule,999999999,1.346,888.44,fee schedule,"191% of Drug Fee Schedule"
"LECANEMAB-IRMB 500 MG/5ML IV SOLN",0250,J0174,62856021501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2538.40 ,1776.88 ,Aetna,"AETNA",2.56,191,fee schedule,999999999,1.346,1776.88,fee schedule,"191% of Drug Fee Schedule"
"MORPHINE SULFATE (PF) 1 MG/ML INJ SOLN",0250,J2274,00409381512,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,53.13 ,37.19 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,78.078,fee schedule,"191% of Drug Fee Schedule"
"MORPHINE SULFATE (PF) 1 MG/ML INJ SOLN",0250,J2274,00641601901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,76.08 ,53.26 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,78.078,fee schedule,"191% of Drug Fee Schedule"
"MORPHINE SULFATE (PF) 1 MG/ML INJ SOLN",0250,J2274,00641601910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,111.54 ,78.08 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,78.078,fee schedule,"191% of Drug Fee Schedule"
"MORPHINE SULFATE (PF) 1 MG/ML INJ SOLN",0250,J2274,00409381511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,53.13 ,37.19 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,78.078,fee schedule,"191% of Drug Fee Schedule"
"NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN",0250,J2305,00338104902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,70.50 ,49.35 ,Aetna,"AETNA",2.75,191,fee schedule,999999999,1.286,49.35,fee schedule,"191% of Drug Fee Schedule"
"OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML PO SUSR",0250,A9270,65628027010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,1629.00 ,1140.30 ,Aetna,"AETNA",733.05,45,percent of total billed charges,999999999,0.03087,1140.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML PO SUSR",0250,A9270,65628027210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,1629.00 ,1140.30 ,Aetna,"AETNA",733.05,45,percent of total billed charges,999999999,0.03087,1140.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY",0250,J0561,60793070210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,2500.00 ,1750.00 ,Aetna,"AETNA",42.02,191,fee schedule,999999999,16.73,1750,fee schedule,"191% of Drug Fee Schedule"
"PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY",0250,J0561,60793070204,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100000,UN  ,,2404.48 ,1683.14 ,Aetna,"AETNA",42.02,191,fee schedule,999999999,16.73,1750,fee schedule,"191% of Drug Fee Schedule"
"HEPARIN NA (PORK) LOCK FLSH PF 1 UNIT/ML IV SOLN",0250,J1642,99999008999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,26.88 ,18.82 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,18.816,fee schedule,"191% of Drug Fee Schedule"
"LAMIVUDINE 150 MG PO TABS",0250,A9270,33342000109,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LAMIVUDINE 10 MG/ML PO SOLN",0250,A9270,57237027424,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,446.40 ,312.48 ,Aetna,"AETNA",200.88,45,percent of total billed charges,999999999,0.03087,312.48,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACARBOSE 50 MG PO TABS",0250,A9270,00054014125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.88 ,4.12 ,Aetna,"AETNA",2.65,45,percent of total billed charges,999999999,0.03087,4.116,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPOPROSTENOL SODIUM 0.5 MG IV SOLR",0250,J1325,62756005940,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,111.00 ,77.70 ,Aetna,"AETNA",29.89,191,fee schedule,999999999,15.86,77.7,fee schedule,"191% of Drug Fee Schedule"
"EPOPROSTENOL SODIUM 1.5 MG IV SOLR",0250,J1325,62756006040,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,222.00 ,155.40 ,Aetna,"AETNA",29.89,191,fee schedule,999999999,15.86,155.4,fee schedule,"191% of Drug Fee Schedule"
"GENTAMICIN IN SALINE 2-0.9 MG/ML-% IV SOLN",0250,J1580,00338051141,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,16.45 ,11.52 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.66,11.515,fee schedule,"191% of Drug Fee Schedule"
"GLYCERIN (LIQUID) 2.8 G PR SUPP",0250,A9270,00132019012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.05 ,7.04 ,Aetna,"AETNA",4.52,45,percent of total billed charges,999999999,0.03087,7.035,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 10 MG/ML PO CONC",0250,A9270,99999007899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 10 MG/ML PO CONC",0250,A9270,00527192736,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSOURCE 1.5 CAL PO LIQD",0250,,43900018150,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.73,45,percent of total billed charges,999999999,3.15,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSOURCE 1.5 CAL PO LIQD",0250,,43900018181,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,3.15,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSOURCE 1.5 CAL PO LIQD",0250,,43900018010,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,11.61 ,8.13 ,Aetna,"AETNA",5.22,45,percent of total billed charges,999999999,3.15,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRETINOIN 10 MG PO CAPS",0250,A9270,68462079201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,0.03087,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLOFITAMAB-GXBM 2.5 MG/2.5ML IV SOLN",0250,J9286,50242012501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,7635.09 ,5344.56 ,Aetna,"AETNA",5170.85,191,fee schedule,999999999,2290.527,5344.563,fee schedule,"191% of Drug Fee Schedule"
"GLOFITAMAB-GXBM 10 MG/10ML IV SOLN",0250,J9286,50242012701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,30540.45 ,21378.32 ,Aetna,"AETNA",5170.85,191,fee schedule,999999999,2707.928,21378.315,fee schedule,"191% of Drug Fee Schedule"
"KCL-LACTATED RINGERS-D5W 20 MEQ/L IV SOLN",0250,,00338081104,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIPOTRIENE 0.005 % EX CREA",0250,A9270,66993087761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,GR,,441.36 ,308.95 ,Aetna,"AETNA",198.61,45,percent of total billed charges,999999999,0.03087,308.952,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RSV PRE-FUSION F A&B VAC RCMB 120 MCG/0.5ML IM SOLR",0250,90678,00069034401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,1249.75 ,874.83 ,Aetna,"AETNA",562.39,45,percent of total billed charges,999999999,312.4375,874.825,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESMOPRESSIN ACETATE 0.1 MG PO TABS",0250,A9270,23155048901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IPRATROPIUM BROMIDE 0.03 % NA SOLN",0250,,69238201603,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,104.58 ,73.21 ,Aetna,"AETNA",47.06,45,percent of total billed charges,999999999,31.374,73.206,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IPRATROPIUM BROMIDE 0.06 % NA SOLN",0250,,69238201702,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,72.09 ,50.46 ,Aetna,"AETNA",32.44,45,percent of total billed charges,999999999,21.627,50.463,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMCICLOVIR 125 MG PO TABS",0250,A9270,00093811756,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.90 ,11.13 ,Aetna,"AETNA",7.16,45,percent of total billed charges,999999999,0.03087,11.13,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMCICLOVIR 125 MG PO TABS",0250,A9270,16714030001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.12 ,7.08 ,Aetna,"AETNA",4.55,45,percent of total billed charges,999999999,0.03087,11.13,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIRSEVIMAB-ALIP 50 MG/0.5ML IM SOSY",0250,90380,49281057500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,1981.85 ,1387.30 ,Aetna,"AETNA",891.83,45,percent of total billed charges,999999999,495.4625,1387.295,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIRSEVIMAB-ALIP 100 MG/ML IM SOSY",0250,90381,49281057488,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,1981.85 ,1387.30 ,Aetna,"AETNA",891.83,45,percent of total billed charges,999999999,495.4625,1387.295,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC 5-11Y PFIZER 10 MCG/0.3ML IM SUSP",0250,91319,59267433101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,108.00 ,75.60 ,Aetna,"AETNA",48.60,45,percent of total billed charges,999999999,27,299.621,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC 5-11Y PFIZER 10 MCG/0.3ML IM SUSP",0250,91319,59267433102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,428.03 ,299.62 ,Aetna,"AETNA",192.61,45,percent of total billed charges,999999999,27,299.621,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC 6M-4Y PFIZER 3 MCG/0.3ML IM SUSP",0250,91318,59267431501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,79.83 ,55.88 ,Aetna,"AETNA",35.92,45,percent of total billed charges,999999999,19.9575,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC 6M-4Y PFIZER 3 MCG/0.3ML IM SUSP",0250,91318,59267431502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,19.9575,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS SULFATE 300 (60 FE) MG/5ML PO SOLN",0250,A9270,39328015705,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,15.54 ,10.88 ,Aetna,"AETNA",6.99,45,percent of total billed charges,999999999,0.03087,10.878,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC-TRIS(PFIZER) 30 MCG/0.3ML IM SUSY",0250,91320,00069239201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,159.93 ,111.95 ,Aetna,"AETNA",71.97,45,percent of total billed charges,999999999,39.9825,466.942,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC-TRIS(PFIZER) 30 MCG/0.3ML IM SUSY",0250,91320,00069239210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,667.06 ,466.94 ,Aetna,"AETNA",300.18,45,percent of total billed charges,999999999,39.9825,466.942,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PETROLATUM EX GEL",0250,A9270,00521234500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,40.95 ,28.67 ,Aetna,"AETNA",18.43,45,percent of total billed charges,999999999,0.03087,28.665,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANASTROZOLE 1 MG PO TABS",0250,A9270,50268007511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANASTROZOLE 1 MG PO TABS",0250,A9270,50268007515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEGFILGRASTIM-CBQV (INF DEV) 6 MG/0.6ML SC SOSY",0250,Q5111,70114013001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,7270.76 ,5089.53 ,Aetna,"AETNA",258.79,191,fee schedule,999999999,122.103,5089.532,fee schedule,"191% of Drug Fee Schedule"
"CALCITRIOL 1 MCG/ML PO SOLN",0250,A9270,00054312041,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,7.66 ,5.36 ,Aetna,"AETNA",3.45,45,percent of total billed charges,999999999,0.03087,5.362,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORDIAZEPOXIDE HCL 25 MG PO CAPS",0250,A9270,00555015902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORDIAZEPOXIDE HCL 5 MG PO CAPS",0250,A9270,00555015802,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GOSERELIN ACETATE 10.8 MG SC IMPL",0250,J9202,70720095130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.6,ME,,7960.80 ,5572.56 ,Aetna,"AETNA",1144.74,191,fee schedule,999999999,572.72,5572.56,fee schedule,"191% of Drug Fee Schedule"
"DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA",0250,A9270,12547017167,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,32.29 ,22.60 ,Aetna,"AETNA",14.53,45,percent of total billed charges,999999999,0.03087,22.603,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IMMUNE GLOBULIN (HUMAN) 5 GM/50ML INJ SOLN (GAMUNEX-C)",0250,J1561,13533080020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",93.36,191,fee schedule,999999999,44.67,1750,fee schedule,"191% of Drug Fee Schedule"
"IMMUNE GLOBULIN (HUMAN) 10 GM/100ML INJ SOLN (GAMUNEX-C)",0250,J1561,13533080071,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,3214.80 ,2250.36 ,Aetna,"AETNA",93.36,191,fee schedule,999999999,44.67,2250.36,fee schedule,"191% of Drug Fee Schedule"
"IMMUNE GLOBULIN (HUMAN) 20 GM/200ML INJ SOLN (GAMUNEX-C)",0250,J1561,13533080024,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,6429.60 ,4500.72 ,Aetna,"AETNA",93.36,191,fee schedule,999999999,44.67,4500.72,fee schedule,"191% of Drug Fee Schedule"
"IMMUNE GLOBULIN (HUMAN) 40 GM/400ML INJ SOLN (GAMUNEX-C)",0250,J1561,13533080040,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12859.20 ,9001.44 ,Aetna,"AETNA",93.36,191,fee schedule,999999999,44.67,9001.44,fee schedule,"191% of Drug Fee Schedule"
"GLIMEPIRIDE 2 MG PO TABS",0250,A9270,68084032601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIMEPIRIDE 2 MG PO TABS",0250,A9270,68084032611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIMEPIRIDE 4 MG PO TABS",0250,A9270,50268036011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIMEPIRIDE 4 MG PO TABS",0250,A9270,50268036015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFEPIME HCL 1 G INJ SOLR",0250,J0692,44567024010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,8.35 ,5.85 ,Aetna,"AETNA",2.56,191,fee schedule,999999999,1.23,5.845,fee schedule,"191% of Drug Fee Schedule"
"CHLORPHENIRAMINE MALEATE 4 MG PO TABS",0250,A9270,00536100601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORPROMAZINE HCL 25 MG PO TABS",0250,A9270,00832601800,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORPROMAZINE HCL 50 MG PO TABS",0250,A9270,00832601900,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORTHALIDONE 25 MG PO TABS",0250,A9270,43598071901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORTHALIDONE 50 MG PO TABS",0250,A9270,43598072001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAROXETINE HCL 10 MG PO TABS",0250,A9270,00904567661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCINE DILUENT IV SOLN",0250,,00173085702,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,105.60 ,73.92 ,Aetna,"AETNA",47.52,45,percent of total billed charges,999999999,31.68,73.92,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRASTUZUMAB 150 MG IV SOLR",0250,J9355,50242013201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4657.50 ,3260.25 ,Aetna,"AETNA",152.90,191,fee schedule,999999999,80.465,3260.25,fee schedule,"191% of Drug Fee Schedule"
"BLEOMYCIN SULFATE 30 UNITS INJ SOLR",0250,J9040,00703315501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,378.24 ,264.77 ,Aetna,"AETNA",44.16,191,fee schedule,999999999,21.024,264.768,fee schedule,"191% of Drug Fee Schedule"
"HYOSCYAMINE SULFATE 0.125 MG SL SUBL",0250,A9270,47781001101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOPOTECAN HCL 4 MG IV SOLR",0250,J9351,25021020606,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,116.64 ,81.65 ,Aetna,"AETNA",2.23,191,fee schedule,999999999,0.5,81.648,fee schedule,"191% of Drug Fee Schedule"
"CIDOFOVIR 75 MG/ML IV SOLN",0250,J0740,23155021631,RC,HCPCS,NDC,FACILITY,OUTPATIENT,375,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",1109.82,191,fee schedule,999999999,550.38,2100,fee schedule,"191% of Drug Fee Schedule"
"MEROPENEM 500 MG IV SOLR",0250,J2185,44567040001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,14.11 ,9.88 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.42,9.877,fee schedule,"191% of Drug Fee Schedule"
"MEROPENEM 500 MG IV SOLR",0250,J2185,44567040010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,14.11 ,9.88 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.42,9.877,fee schedule,"191% of Drug Fee Schedule"
"MEROPENEM 1 G IV SOLR",0250,J2185,44567040101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,30.63 ,21.44 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.42,21.441,fee schedule,"191% of Drug Fee Schedule"
"MEROPENEM 1 G IV SOLR",0250,J2185,44567040110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,30.63 ,21.44 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.42,21.441,fee schedule,"191% of Drug Fee Schedule"
"AZITHROMYCIN 600 MG PO TABS",0250,A9270,00781149731,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,44.32 ,31.02 ,Aetna,"AETNA",19.94,45,percent of total billed charges,999999999,0.03087,31.024,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZITHROMYCIN 600 MG PO TABS",0250,A9270,64679096201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.63 ,21.44 ,Aetna,"AETNA",13.78,45,percent of total billed charges,999999999,0.03087,31.024,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINDAMYCIN HCL 150 MG PO CAPS",0250,A9270,00904595961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEVIRAPINE 200 MG PO TABS",0250,A9270,31722050560,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MELATONIN 5 MG PO TABS",0250,A9270,20555003901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETOPOSIDE PHOSPHATE 100 MG IV SOLR",0250,J9181,00015340420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,871.02 ,609.71 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.7,609.714,fee schedule,"191% of Drug Fee Schedule"
"MIRTAZAPINE 30 MG PO TABS",0250,A9270,51079008701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 30 MG PO TABS",0250,A9270,51079008720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 15 MG PO TABS",0250,A9270,63739035510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 15 MG PO TABS",0250,A9270,00904651961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE HCL 0.1 MG PO TABS",0250,A9270,60687011301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE HCL 0.2 MG PO TABS",0250,A9270,60687012401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE HCL 0.2 MG PO TABS",0250,A9270,60687012411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS",0250,A9270,13107031901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.09 ,4.26 ,Aetna,"AETNA",2.74,45,percent of total billed charges,999999999,0.03087,4.263,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOTRIMAZOLE 1 % EX CREA",0250,A9270,51672127501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,15.33 ,10.73 ,Aetna,"AETNA",6.90,45,percent of total billed charges,999999999,0.03087,10.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOTRIMAZOLE 1 % VA CREA",0250,A9270,51672200306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,45,GR,,27.09 ,18.96 ,Aetna,"AETNA",12.19,45,percent of total billed charges,999999999,0.03087,18.963,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT INH AERS",0250,A9270,00173068220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,318.49 ,222.94 ,Aetna,"AETNA",143.32,45,percent of total billed charges,999999999,0.03087,222.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT INH AERS",0250,A9270,00173068224,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,125.66 ,87.96 ,Aetna,"AETNA",56.55,45,percent of total billed charges,999999999,0.03087,222.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT INH AERS",0250,A9270,68180096301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,139.18 ,97.43 ,Aetna,"AETNA",62.63,45,percent of total billed charges,999999999,0.03087,222.943,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 5-325 MG/5ML PO SOLN",0250,,99999013699,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 5-325 MG/5ML PO SOLN",0250,,00054864816,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,1.5,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRIMONIDINE TARTRATE 0.2 % OP SOLN",0250,A9270,61314014305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,33.25 ,23.28 ,Aetna,"AETNA",14.96,45,percent of total billed charges,999999999,0.03087,39.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRIMONIDINE TARTRATE 0.2 % OP SOLN",0250,A9270,61314014310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,55.72 ,39.00 ,Aetna,"AETNA",25.07,45,percent of total billed charges,999999999,0.03087,39.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLANZAPINE 5 MG PO TABS",0250,A9270,55111016430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLANZAPINE 5 MG PO TABS",0250,A9270,43598016430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZAFIRLUKAST 20 MG PO TABS",0250,A9270,31722000860,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028523,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,42.70 ,29.89 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,76.02,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,108.60 ,76.02 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,76.02,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028507,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,42.70 ,29.89 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,76.02,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,108.60 ,76.02 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,76.02,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 10 MG/ML INJ SOLN",0250,J2795,63323028821,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,35.70 ,24.99 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,24.99,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 10 MG/ML INJ SOLN",0250,J2795,63323028807,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,35.70 ,24.99 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,24.99,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 5 MG/ML INJ SOLN",0250,J2795,70069006401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.53 ,3.87 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,3.871,fee schedule,"191% of Drug Fee Schedule"
"ROPIVACAINE HCL 5 MG/ML INJ SOLN",0250,J2795,70069006410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,3.871,fee schedule,"191% of Drug Fee Schedule"
"COLCHICINE 0.6 MG PO TABS",0250,A9270,70010000201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BISOPROLOL FUMARATE 5 MG PO TABS",0250,A9270,70954045520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TORSEMIDE 20 MG PO TABS",0250,A9270,50268075611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TORSEMIDE 20 MG PO TABS",0250,A9270,50268075615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TORSEMIDE 100 MG PO TABS",0250,A9270,50268075711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TORSEMIDE 100 MG PO TABS",0250,A9270,50268075715,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TORSEMIDE 5 MG PO TABS",0250,A9270,50111091501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR",0250,J2543,60505615900,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,19.16 ,13.41 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,13.412,fee schedule,"191% of Drug Fee Schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR",0250,J2543,60505615904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,19.16 ,13.41 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,13.412,fee schedule,"191% of Drug Fee Schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR",0250,J2543,60505615700,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,13.01 ,9.11 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,9.107,fee schedule,"191% of Drug Fee Schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR",0250,J2543,60505615704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,13.01 ,9.11 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,9.107,fee schedule,"191% of Drug Fee Schedule"
"PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR",0250,J2543,55150011930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,9.94 ,6.96 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,6.958,fee schedule,"191% of Drug Fee Schedule"
"GABAPENTIN 400 MG PO CAPS",0250,A9270,67877022401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GABAPENTIN 300 MG PO CAPS",0250,A9270,60687059101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GABAPENTIN 300 MG PO CAPS",0250,A9270,60687059111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GABAPENTIN 100 MG PO CAPS",0250,A9270,45963055550,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RISPERIDONE 2 MG PO TABS",0250,A9270,00904736361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RISPERIDONE 3 MG PO TABS",0250,A9270,00904736461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RISPERIDONE 1 MG PO TABS",0250,A9270,00904736261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN",0250,J1250,00338107302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,43.75 ,30.63 ,Aetna,"AETNA",17.69,191,fee schedule,999999999,6.54,30.625,fee schedule,""
"BUPROPION HCL ER (SR) 100 MG PO TB12",0250,A9270,00185041060,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.97 ,5.58 ,Aetna,"AETNA",3.59,45,percent of total billed charges,999999999,0.03087,5.579,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPROPION HCL ER (SR) 150 MG PO TB12",0250,A9270,68084070895,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.97 ,4.18 ,Aetna,"AETNA",2.69,45,percent of total billed charges,999999999,0.03087,4.179,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DHEA 25 MG PO CAPS",0250,A9270,40985021177,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REMIFENTANIL HCL 1 MG IV SOLR",0250,,63323072301,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,221.23 ,154.86 ,Aetna,"AETNA",99.55,45,percent of total billed charges,999999999,66.369,154.861,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REMIFENTANIL HCL 1 MG IV SOLR",0250,,63323072303,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,221.23 ,154.86 ,Aetna,"AETNA",99.55,45,percent of total billed charges,999999999,66.369,154.861,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REMIFENTANIL HCL 2 MG IV SOLR",0250,,67457019805,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,684.81 ,479.37 ,Aetna,"AETNA",308.16,45,percent of total billed charges,999999999,205.443,479.367,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 3.125 MG PO TABS",0250,A9270,00093005101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 3.125 MG PO TABS",0250,A9270,00093005105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COMPLEAT PO LIQD",0250,,43900014010,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,22.75 ,15.93 ,Aetna,"AETNA",10.24,45,percent of total billed charges,999999999,5.775,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COMPLEAT PO LIQD",0250,,43900014180,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,5.775,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COMPLEAT PO LIQD",0250,,43900014240,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,19.25 ,13.48 ,Aetna,"AETNA",8.66,45,percent of total billed charges,999999999,5.775,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LATANOPROST 0.005 % OP SOLN",0250,A9270,61314054701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ML,,40.32 ,28.22 ,Aetna,"AETNA",18.14,45,percent of total billed charges,999999999,0.03087,28.224,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DONEPEZIL HCL 5 MG PO TABS",0250,A9270,00904647761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ELLIOTTS B IT SOLN",0250,,55792000710,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,545.28 ,381.70 ,Aetna,"AETNA",245.38,45,percent of total billed charges,999999999,163.584,381.696,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NUTREN JUNIOR/FIBER PO LIQD",0250,,98716006063,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONDANSETRON HCL 4 MG/5ML PO SOLN",0250,A9270,00054006447,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.96 ,8.37 ,Aetna,"AETNA",5.38,45,percent of total billed charges,999999999,0.03087,8.372,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN",0250,,70436002880,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,62.86 ,44.00 ,Aetna,"AETNA",28.29,45,percent of total billed charges,999999999,18.858,44.002,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 250 MG PO TABS",0250,A9270,00904635161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 500 MG PO TABS",0250,A9270,50458092550,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,168.91 ,118.24 ,Aetna,"AETNA",76.01,45,percent of total billed charges,999999999,0.03087,118.237,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 500 MG PO TABS",0250,A9270,00904635261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,118.237,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOPIRAMATE 25 MG PO TABS",0250,A9270,00904692861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOPIRAMATE 100 MG PO TABS",0250,,00904692961,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 25 MG/ML IV SOLN",0250,J1956,17478010720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,76.20 ,53.34 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,53.34,fee schedule,""
"LEVOFLOXACIN 25 MG/ML IV SOLN",0250,J1956,36000004501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,9.94 ,6.96 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.908,53.34,fee schedule,""
"ATORVASTATIN CALCIUM 10 MG PO TABS",0250,A9270,00904629061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATORVASTATIN CALCIUM 40 MG PO TABS",0250,A9270,00904629261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATORVASTATIN CALCIUM 20 MG PO TABS",0250,A9270,00904629161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE HCL (ANALGESIA) 100 MCG/ML EPID SOLN",0250,J0735,39822200001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,94.98 ,66.49 ,Aetna,"AETNA",32.51,191,fee schedule,999999999,18.47,66.486,fee schedule,""
"CORTISONE ACETATE 25 MG PO TABS",0250,A9270,00143120201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.03 ,11.22 ,Aetna,"AETNA",7.21,45,percent of total billed charges,999999999,0.03087,11.221,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CORTISONE ACETATE 25 MG PO TABS",0250,A9270,00143970001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.96 ,5.57 ,Aetna,"AETNA",3.58,45,percent of total billed charges,999999999,0.03087,11.221,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 3 MG PO TABS",0250,A9270,00832121401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 6 MG PO TABS",0250,A9270,00832121700,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE HCL (NASAL) 0.1 % NA SOLN",0250,,42023010301,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,1162.05 ,813.44 ,Aetna,"AETNA",522.92,45,percent of total billed charges,999999999,348.615,813.435,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL 10 % OP SOLN",0250,,70756061430,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,181.14 ,126.80 ,Aetna,"AETNA",81.51,45,percent of total billed charges,999999999,54.342,126.798,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BETAXOLOL HCL 0.25 % OP SUSP",0250,A9270,00078072910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,1718.30 ,1202.81 ,Aetna,"AETNA",773.24,45,percent of total billed charges,999999999,0.03087,1202.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBACHOL 0.01 % IO SOLN",0250,,00065002315,RC,,NDC,FACILITY,OUTPATIENT,1.5,ML,,235.48 ,164.84 ,Aetna,"AETNA",105.97,45,percent of total billed charges,999999999,70.644,164.836,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETOROLAC TROMETHAMINE 0.5 % OP SOLN",0250,,42571013725,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,50.12 ,35.08 ,Aetna,"AETNA",22.55,45,percent of total billed charges,999999999,15.036,35.084,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORETHINDRONE 0.35 MG PO TABS",0250,A9270,68180087671,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORETHINDRONE 0.35 MG PO TABS",0250,A9270,68180087673,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CROMOLYN SODIUM 100 MG/5ML PO CONC",0250,A9270,16571060096,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,29.12 ,20.38 ,Aetna,"AETNA",13.10,45,percent of total billed charges,999999999,0.03087,20.384,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SERTRALINE HCL 25 MG PO TABS",0250,A9270,60687023101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SERTRALINE HCL 25 MG PO TABS",0250,A9270,60687023111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ITRACONAZOLE 10 MG/ML PO SOLN",0250,A9270,31722000631,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,60.00 ,42.00 ,Aetna,"AETNA",27.00,45,percent of total billed charges,999999999,0.03087,42,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN CIWA",0250,J2560,00641047721,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,220.36 ,154.25 ,Aetna,"AETNA",62.65,191,fee schedule,999999999,31.432,154.252,fee schedule,""
"PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN CIWA",0250,J2560,00641047725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,220.36 ,154.25 ,Aetna,"AETNA",62.65,191,fee schedule,999999999,31.432,154.252,fee schedule,""
"J-TIP BUFFERED LIDOCAINE 1% SYRINGE",0250,,70004072501,RC,,NDC,FACILITY,OUTPATIENT,0.25,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 50% CONTINUOUS INFUSION",0250,,00409793619,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,38.50 ,26.95 ,Aetna,"AETNA",17.33,45,percent of total billed charges,999999999,11.55,26.95,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYANOCOBALAMIN 1000 MCG/ML INJ SOLN",0250,J3420,16729053308,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,mcg,,22.41 ,15.69 ,Aetna,"AETNA",2.71,191,fee schedule,999999999,1.31,15.687,fee schedule,""
"MESNA 400 MG PO TABS",0250,A9270,67108356509,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,391.06 ,273.74 ,Aetna,"AETNA",175.98,45,percent of total billed charges,999999999,0.03087,273.742,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCERIN EX CREA",0250,A9270,61924017404,RC,HCPCS,NDC,FACILITY,OUTPATIENT,113,GR,,28.20 ,19.74 ,Aetna,"AETNA",12.69,45,percent of total billed charges,999999999,0.03087,19.74,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROPHOR EX OINT",0250,A9270,72140045231,RC,HCPCS,NDC,FACILITY,OUTPATIENT,454,GR,,43.75 ,30.63 ,Aetna,"AETNA",19.69,45,percent of total billed charges,999999999,0.03087,30.625,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROPHOR EX OINT",0250,A9270,72140011047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,454,GR,,21.77 ,15.24 ,Aetna,"AETNA",9.80,45,percent of total billed charges,999999999,0.03087,30.625,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYTARABINE (PF) 100 MG/ML INJ SOLN",0250,J9100,63323012020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.92,49,fee schedule,""
"CYCLOBENZAPRINE HCL 10 MG PO TABS",0250,A9270,50268019111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOBENZAPRINE HCL 10 MG PO TABS",0250,A9270,50268019115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPENTOLATE HCL 1 % OP SOLN",0250,,24208073506,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,161.55 ,113.09 ,Aetna,"AETNA",72.70,45,percent of total billed charges,999999999,6.657,113.085,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPENTOLATE HCL 1 % OP SOLN",0250,,61314039601,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,22.19 ,15.53 ,Aetna,"AETNA",9.99,45,percent of total billed charges,999999999,6.657,113.085,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYPROHEPTADINE HCL 2 MG/5ML PO SYRP",0250,A9270,64980050448,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYPROHEPTADINE HCL 4 MG PO TABS",0250,A9270,52817021010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETOMIDATE 2 MG/ML IV SOLN",0250,J3490,65219044501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,14.21 ,9.95 ,Aetna,"AETNA",6.39,45,percent of total billed charges,999999999,0,9.947,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETOMIDATE 2 MG/ML IV SOLN",0250,J3490,65219044510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,14.21 ,9.95 ,Aetna,"AETNA",6.39,45,percent of total billed charges,999999999,0,9.947,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMANTADINE HCL 100 MG PO TABS",0250,A9270,00832011100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MELOXICAM 7.5 MG PO TABS",0250,A9270,50268052515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MELOXICAM 7.5 MG PO TABS",0250,A9270,50268052511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROATE SODIUM 100 MG/ML IV SOLN",0250,J3490,63323049401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.64 ,8.85 ,Aetna,"AETNA",5.69,45,percent of total billed charges,999999999,0,8.848,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALPROATE SODIUM 100 MG/ML IV SOLN",0250,J3490,63323049405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.64 ,8.85 ,Aetna,"AETNA",5.69,45,percent of total billed charges,999999999,0,8.848,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DACARBAZINE 100 MG IV SOLR",0250,J9130,63323012700,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,67.00 ,46.90 ,Aetna,"AETNA",7.05,191,fee schedule,999999999,3.733,46.9,fee schedule,""
"DACARBAZINE 100 MG IV SOLR",0250,J9130,63323012710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,67.00 ,46.90 ,Aetna,"AETNA",7.05,191,fee schedule,999999999,3.733,46.9,fee schedule,""
"DACARBAZINE 200 MG IV SOLR",0250,J9130,63323012820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,42.56 ,29.79 ,Aetna,"AETNA",7.05,191,fee schedule,999999999,3.733,29.792,fee schedule,""
"AZITHROMYCIN 250 MG PO TABS",0250,A9270,50268007415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOCARNITINE 330 MG PO TABS",0250,A9270,16571076209,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.53 ,4.57 ,Aetna,"AETNA",2.94,45,percent of total billed charges,999999999,0.03087,4.571,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOCARNITINE 200 MG/ML IV SOLN",0250,J1955,00143985210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,136.86 ,95.80 ,Aetna,"AETNA",67.12,191,fee schedule,999999999,28.04,95.802,fee schedule,""
"LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT",0250,J1950,00074366303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.75,ME,,14374.53 ,10062.17 ,Aetna,"AETNA",3010.39,191,fee schedule,999999999,1477.55,10062.171,fee schedule,""
"LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT",0250,J9217,00074334603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ME,,17129.28 ,11990.50 ,Aetna,"AETNA",354.61,191,fee schedule,999999999,165.86,11990.496,fee schedule,""
"OLANZAPINE 2.5 MG PO TABS",0250,A9270,00904628361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXCARBAZEPINE 300 MG PO TABS",0250,A9270,00904726361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CITALOPRAM HYDROBROMIDE 20 MG PO TABS",0250,A9270,57664050888,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZITHROMYCIN 500 MG IV SOLR",0250,J0456,55150017410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.58 ,8.81 ,Aetna,"AETNA",4.60,191,fee schedule,999999999,1.79,8.806,fee schedule,""
"LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT",0250,J9217,00074368303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ME,,22839.09 ,15987.36 ,Aetna,"AETNA",354.61,191,fee schedule,999999999,165.86,15987.363,fee schedule,""
"EDETATE DISODIUM DIHYDRATE POWD",0250,,51552058804,RC,,NDC,FACILITY,OUTPATIENT,100,GR,,147.60 ,103.32 ,Aetna,"AETNA",66.42,45,percent of total billed charges,999999999,44.28,103.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CORTICORELIN OVINE TRIFLUTATE 100 MCG IV SOLR",0250,J0795,55566030201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3000.00 ,2100.00 ,Aetna,"AETNA",20.91,191,fee schedule,999999999,0.01,2100,fee schedule,""
"PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS",0250,A9270,13668009190,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS",0250,A9270,00904670461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOXIFYLLINE ER 400 MG PO TBCR",0250,A9270,51079088920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOXIFYLLINE ER 400 MG PO TBCR",0250,A9270,60505003306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOXIFYLLINE ER 400 MG PO TBCR",0250,A9270,00093511601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAPSONE 100 MG PO TABS",0250,A9270,70954013610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAPSONE 25 MG PO TABS",0250,A9270,70954013510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROGESTERONE 8 % VA GEL",0250,A9270,00023615108,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.41 ,9.39 ,Aetna,"AETNA",6.03,45,percent of total billed charges,999999999,0.03087,9.387,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROGESTERONE 8 % VA GEL",0250,A9270,00023615109,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.35 ,9.35 ,Aetna,"AETNA",6.01,45,percent of total billed charges,999999999,0.03087,9.387,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 4 MG PO TABS",0250,A9270,00832121500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LETROZOLE 2.5 MG PO TABS",0250,A9270,00093762056,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NOVASOURCE RENAL PO LIQD",0250,,43900035180,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,102.00 ,71.40 ,Aetna,"AETNA",45.90,45,percent of total billed charges,999999999,30.6,71.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FEXOFENADINE HCL 60 MG PO TABS",0250,A9270,41167413104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.12 ,3.58 ,Aetna,"AETNA",2.30,45,percent of total billed charges,999999999,0.03087,3.584,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR",0250,J8999,24338005008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.7,ME,,116256.79 ,81379.75 ,Aetna,"AETNA",52315.56,45,percent of total billed charges,999999999,0,81379.753,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 0.25 MG PO TABS",0250,A9270,68462025301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 1 MG PO TABS",0250,A9270,00904637461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 2 MG PO TABS",0250,A9270,50268074415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ICY HOT BALM EXTRA STRENGTH 7.6-29 % EX OINT",0250,A9270,41167000879,RC,HCPCS,NDC,FACILITY,OUTPATIENT,28,GR,,27.78 ,19.45 ,Aetna,"AETNA",12.50,45,percent of total billed charges,999999999,0.03087,19.446,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 0.5 MG PO TABS",0250,A9270,00054011725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 0.5 MG PO TABS",0250,A9270,68462025401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPINIROLE HCL 0.5 MG PO TABS",0250,A9270,43547026910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXYCYCLINE MONOHYDRATE 100 MG PO TABS",0250,A9270,60687034425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.38 ,9.37 ,Aetna,"AETNA",6.02,45,percent of total billed charges,999999999,0.03087,9.366,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXYCYCLINE MONOHYDRATE 100 MG PO TABS",0250,A9270,60687034495,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.54 ,8.78 ,Aetna,"AETNA",5.64,45,percent of total billed charges,999999999,0.03087,9.366,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 25 MG PO TABS",0250,A9270,00310027510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.32 ,17.72 ,Aetna,"AETNA",11.39,45,percent of total billed charges,999999999,0.03087,17.724,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 25 MG PO TABS",0250,A9270,47335090288,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,17.724,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 100 MG PO TABS",0250,A9270,00310027110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,43.46 ,30.42 ,Aetna,"AETNA",19.56,45,percent of total billed charges,999999999,0.03087,30.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 100 MG PO TABS",0250,A9270,47335090488,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,30.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 200 MG PO TABS",0250,A9270,47335090588,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.12 ,4.28 ,Aetna,"AETNA",2.75,45,percent of total billed charges,999999999,0.03087,5.11,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 200 MG PO TABS",0250,A9270,60505313501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.30 ,5.11 ,Aetna,"AETNA",3.29,45,percent of total billed charges,999999999,0.03087,5.11,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IRBESARTAN 150 MG PO TABS",0250,A9270,31722073090,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACLOFEN 0.05 MG/ML IT SOLN",0250,J0476,70257056255,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,mcg,,90.00 ,63.00 ,Aetna,"AETNA",110.61,191,fee schedule,999999999,27,110.6081,fee schedule,""
"AMPHOTERICIN B LIPOSOME 50 MG IV SUSR",0250,J0289,00469305130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,397.74 ,278.42 ,Aetna,"AETNA",52.87,191,fee schedule,999999999,25.9,278.418,fee schedule,""
"CLOPIDOGREL BISULFATE 75 MG PO TABS",0250,A9270,00904629461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RALOXIFENE HCL 60 MG PO TABS",0250,A9270,69097082502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RITUXIMAB 10 MG/ML IV CONC (S-ORDERABLE)",0250,,50242005121,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,750,9827.475,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RITUXIMAB 10 MG/ML IV CONC (S-ORDERABLE)",0250,,50242005306,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,14039.25 ,9827.48 ,Aetna,"AETNA",6317.66,45,percent of total billed charges,999999999,750,9827.475,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FOMEPIZOLE 1 GM/ML IV SOLN",0250,J1451,00517071001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",28.96,191,fee schedule,999999999,12.89,1750,fee schedule,""
"MUPIROCIN CALCIUM 2 % EX CREA",0250,,21922002905,RC,,NDC,FACILITY,OUTPATIENT,30,GR,,225.72 ,158.00 ,Aetna,"AETNA",101.57,45,percent of total billed charges,999999999,67.716,158.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFDINIR 300 MG PO CAPS",0250,A9270,65862017760,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENHYDRAMINE-ZINC ACETATE 1-0.1 % EX CREA",0250,A9270,12547017162,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,31.89 ,22.32 ,Aetna,"AETNA",14.35,45,percent of total billed charges,999999999,0.03087,22.323,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM ACETATE (PHOS BINDER) 667 MG PO TABS",0250,A9270,71321080320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN",0250,J1885,00409379301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,5.60 ,3.92 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.488,9.016,fee schedule,""
"KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN",0250,J1885,00409379319,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,12.88 ,9.02 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.488,9.016,fee schedule,""
"KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN",0250,J1885,00409379501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.488,3.5,fee schedule,""
"KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN",0250,J1885,00409379519,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.488,3.5,fee schedule,""
"MONTELUKAST SODIUM 10 MG PO TABS",0250,A9270,00904680861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MONTELUKAST SODIUM 5 MG PO CHEW",0250,A9270,00603465416,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.49 ,4.54 ,Aetna,"AETNA",2.92,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MONTELUKAST SODIUM 5 MG PO CHEW",0250,A9270,00781555531,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP",0250,A9270,99999002399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,156.94,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP",0250,A9270,70954025810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,224.20 ,156.94 ,Aetna,"AETNA",100.89,45,percent of total billed charges,999999999,0.03087,156.94,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML PO SOLN",0250,A9270,00121067616,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,60.00 ,42.00 ,Aetna,"AETNA",27.00,45,percent of total billed charges,999999999,0.03087,42,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS",0250,A9270,60687058111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAMIPEXOLE DIHYDROCHLORIDE 0.5 MG PO TABS",0250,A9270,60687058121,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESIPRAMINE HCL 10 MG PO TABS",0250,A9270,23155057801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESONIDE 0.05 % EX CREA",0250,A9270,62332063215,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,52.50 ,36.75 ,Aetna,"AETNA",23.63,45,percent of total billed charges,999999999,0.03087,36.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BRINZOLAMIDE 1 % OP SUSP",0250,A9270,00574401210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,832.80 ,582.96 ,Aetna,"AETNA",374.76,45,percent of total billed charges,999999999,0.03087,582.96,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENOFIBRATE MICRONIZED 67 MG PO CAPS",0250,A9270,62332008431,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN",0250,A9270,24208048610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,54.81 ,38.37 ,Aetna,"AETNA",24.66,45,percent of total billed charges,999999999,0.03087,38.367,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN-HYDROCORTISONE 0.2-1 % OT SUSP",0250,,00078085526,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,1696.90 ,1187.83 ,Aetna,"AETNA",763.61,45,percent of total billed charges,999999999,509.07,1187.83,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS",0250,A9270,00781187431,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.02 ,7.01 ,Aetna,"AETNA",4.51,45,percent of total billed charges,999999999,0.03087,7.014,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MENTHOL MT LOZENGE (WRAPPER)",0250,A9270,12546005079,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PSYLLIUM PO PACK (WRAPPER)",0250,A9270,37000025445,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323049237,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323049257,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,25.62 ,17.93 ,Aetna,"AETNA",11.53,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323048527,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,11.76 ,8.23 ,Aetna,"AETNA",5.29,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323049227,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,15.39 ,10.77 ,Aetna,"AETNA",6.93,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323048501,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,11.76 ,8.23 ,Aetna,"AETNA",5.29,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN (WRAPPER)",0250,,63323020110,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,22.12 ,15.48 ,Aetna,"AETNA",9.95,45,percent of total billed charges,999999999,3.528,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,63807010011,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,7.54 ,5.28 ,Aetna,"AETNA",3.39,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,00409488812,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,4.33 ,3.03 ,Aetna,"AETNA",1.95,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,08881570121,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,08881570300,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.21 ,3.65 ,Aetna,"AETNA",2.34,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,00409488803,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,63323018603,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.9% INJ SOLN (WRAPPER)",0250,,63323018620,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,5.278,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL 10 MG/ML INJ SOLN (WRAPPER)",0250,J2371,70069080101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,6.70 ,4.69 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,43.365,fee schedule,""
"PHENYLEPHRINE HCL 10 MG/ML INJ SOLN (WRAPPER)",0250,J2371,70069080125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,6.70 ,4.69 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,43.365,fee schedule,""
"PHENYLEPHRINE HCL 10 MG/ML INJ SOLN (WRAPPER)",0250,J2371,70069080301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,61.95 ,43.37 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,43.365,fee schedule,""
"GLUCOSE 4 G PO CHEW (WRAPPER)",0250,A9270,56151161111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,0.03087,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP (WRAPPER)",0250,J1050,59762453701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,136.14 ,95.30 ,Aetna,"AETNA",1.24,191,fee schedule,999999999,0.01,238.623,fee schedule,""
"MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP (WRAPPER)",0250,J1050,59762453702,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,340.89 ,238.62 ,Aetna,"AETNA",1.24,191,fee schedule,999999999,0.01,238.623,fee schedule,""
"RITUXIMAB-PVVR 10 MG/1 ML IV SOLN (WRAPPER)",0250,,00069023801,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,1930.15 ,1351.11 ,Aetna,"AETNA",868.57,45,percent of total billed charges,999999999,482.5375,4053,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RITUXIMAB-PVVR 10 MG/1 ML IV SOLN (WRAPPER)",0250,,00069024901,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,5790.00 ,4053.00 ,Aetna,"AETNA",2605.50,45,percent of total billed charges,999999999,482.5375,4053,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIDAZOLAM HCL 5 MG/ML INJ SOLN (WRAPPER)",0250,J2250,00409230801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,6.26 ,4.38 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,4.382,fee schedule,""
"GLUCAGON HCL (DIAGNOSTIC) 1 MG INJ SOLR (WRAPPER)",0250,J1611,63323059613,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,257.97 ,180.58 ,Aetna,"AETNA",246.16,191,fee schedule,999999999,64.4925,246.1608,fee schedule,""
"GLUCAGON HCL (DIAGNOSTIC) 1 MG INJ SOLR (WRAPPER)",0250,J1611,63323059611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,257.97 ,180.58 ,Aetna,"AETNA",246.16,191,fee schedule,999999999,64.4925,246.1608,fee schedule,""
"VITAMIN B1 100 MG PO TABS (WRAPPER)",0250,A9270,37864090599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,00409128331,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,12.64 ,8.85 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,00409255201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,7.17 ,5.02 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,00409255211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,7.17 ,5.02 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,63323085203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,20.08 ,14.06 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,63323085225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,20.08 ,14.06 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,76045000901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,13.72 ,9.60 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"HYDROMORPHONE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J1170,76045000911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,15.97 ,11.18 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,2.151,14.056,fee schedule,""
"LANOLIN-PETROLATUM EX OINT (WRAPPER)",0250,A9270,65197040010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,23.66 ,16.56 ,Aetna,"AETNA",10.65,45,percent of total billed charges,999999999,0.03087,16.562,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE 1 MG/10ML INJ (WRAPPER)",0250,J0171,00409493301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,53.62 ,37.53 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,37.534,fee schedule,""
"EPINEPHRINE 1 MG/10ML INJ (WRAPPER)",0250,J0171,00409493311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,48.79 ,34.15 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,37.534,fee schedule,""
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,63323048617,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,13.37 ,9.36 ,Aetna,"AETNA",6.02,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,63323048627,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,11.20 ,7.84 ,Aetna,"AETNA",5.04,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,00143959401,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,00143959425,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,63323048602,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,11.20 ,7.84 ,Aetna,"AETNA",5.04,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN (WRAPPER)",0250,,63323020202,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,21.49 ,15.04 ,Aetna,"AETNA",9.67,45,percent of total billed charges,999999999,2.172,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 10 MG/ML IV SOLN (WRAPPER)",0250,J2270,00641612701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.64 ,10.25 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,10.248,fee schedule,""
"MORPHINE SULFATE 10 MG/ML IV SOLN (WRAPPER)",0250,J2270,00641612725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.64 ,10.25 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,10.248,fee schedule,""
"CLEVIDIPINE 0.5 MG/ML IV EMUL (WRAPPER)",0250,C9248,10122061001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,454.80 ,318.36 ,Aetna,"AETNA",7.85,191,fee schedule,999999999,3.32,630,fee schedule,""
"CLEVIDIPINE 0.5 MG/ML IV EMUL (WRAPPER)",0250,C9248,10122061010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,468.60 ,328.02 ,Aetna,"AETNA",7.85,191,fee schedule,999999999,3.32,630,fee schedule,""
"CLEVIDIPINE 0.5 MG/ML IV EMUL (WRAPPER)",0250,C9248,10122061110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,900.00 ,630.00 ,Aetna,"AETNA",7.85,191,fee schedule,999999999,3.32,630,fee schedule,""
"RITUXIMAB-ARRX 10 MG/1 ML IV SOLN (WRAPPER)",0250,Q5123,55513022401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2774.00 ,1941.80 ,Aetna,"AETNA",79.11,191,fee schedule,999999999,40.78,7281.75,fee schedule,""
"RITUXIMAB-ARRX 10 MG/1 ML IV SOLN (WRAPPER)",0250,Q5123,55513032601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,10402.50 ,7281.75 ,Aetna,"AETNA",79.11,191,fee schedule,999999999,40.78,7281.75,fee schedule,""
"MORPHINE SULFATE 4 MG/ML IV SOLN (WRAPPER)",0250,J2272,63323045400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",13.90,191,fee schedule,999999999,1.25,13.9048,fee schedule,""
"MORPHINE SULFATE 4 MG/ML IV SOLN (WRAPPER)",0250,J2272,63323045401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",13.90,191,fee schedule,999999999,1.25,13.9048,fee schedule,""
"RITUXIMAB-ABBS 10 MG/1 ML IV SOLN (WRAPPER)",0250,,63459010310,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,2413.30 ,1689.31 ,Aetna,"AETNA",1085.99,45,percent of total billed charges,999999999,603.325,5067.93,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RITUXIMAB-ABBS 10 MG/1 ML IV SOLN (WRAPPER)",0250,,63459010450,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,7239.90 ,5067.93 ,Aetna,"AETNA",3257.96,45,percent of total billed charges,999999999,603.325,5067.93,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE 1 MG/10 ML INJ (POST CARDIAC SURGERY NARRATOR)",0250,J0171,00409493301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,3.5,fee schedule,""
"EPINEPHRINE 1 MG/10 ML INJ (POST CARDIAC SURGERY NARRATOR)",0250,J0171,00409493311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,3.5,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 1000 MG INJ SOLR (WRAPPER)",0250,J2919,63323026530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,49,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 125 MG INJ SOLR (WRAPPER)",0250,J2919,00009004722,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,26.99 ,18.89 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,18.893,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 125 MG INJ SOLR (WRAPPER)",0250,J2919,00009004725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,23.46 ,16.42 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,18.893,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 40 MG INJ SOLR (WRAPPER)",0250,J2919,00009003928,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,16.98 ,11.89 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,11.886,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 40 MG INJ SOLR (WRAPPER)",0250,J2919,00009003930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,14.74 ,10.32 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,11.886,fee schedule,""
"METHYLPREDNISOLONE SODIUM SUCC 500 MG INJ SOLR (WRAPPER)",0250,J2919,00143985001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,90.18 ,63.13 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.3,63.126,fee schedule,""
"HEPARIN SOD (PORK) LOCK FLUSH 10 UNIT/ML IV SOLN (WRAPPER)",0250,J1642,64253022235,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,3.5,fee schedule,""
"HEPARIN SOD (PORK) LOCK FLUSH 100 UNIT/ML IV SOLN (WRAPPER)",0250,J1642,64253033335,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,3.5,fee schedule,""
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML PO LIQD (WRAPPER)",0250,A9270,57896073604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN (WRAPPER)",0250,,42023021601,RC,,NDC,FACILITY,OUTPATIENT,0.1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPHEDRINE SULFATE (PRESSORS) 50 MG/ML IV SOLN (WRAPPER)",0250,,42023021625,RC,,NDC,FACILITY,OUTPATIENT,0.1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 50 MG/ML INJ SOLN (WRAPPER)",0250,,00143950801,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,39.48 ,27.64 ,Aetna,"AETNA",17.77,45,percent of total billed charges,999999999,9.051,33.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 50 MG/ML INJ SOLN (WRAPPER)",0250,,00143950810,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,39.48 ,27.64 ,Aetna,"AETNA",17.77,45,percent of total billed charges,999999999,9.051,33.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 50 MG/ML INJ SOLN (WRAPPER)",0250,,70092112043,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,30.17 ,21.12 ,Aetna,"AETNA",13.58,45,percent of total billed charges,999999999,9.051,33.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 50 MG/ML INJ SOLN (WRAPPER)",0250,,70092912043,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,47.60 ,33.32 ,Aetna,"AETNA",21.42,45,percent of total billed charges,999999999,9.051,33.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATROPINE SULFATE 0.4 MG/ML IV SOLN (WRAPPER)",0250,J0461,00517100401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,29.72 ,20.80 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,20.804,fee schedule,""
"ATROPINE SULFATE 0.4 MG/ML IV SOLN (WRAPPER)",0250,J0461,00517100425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,29.72 ,20.80 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,20.804,fee schedule,""
"ATROPINE SULFATE 1 MG/ML INJ SOLN (WRAPPER)",0250,J0461,00517101025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,19.33 ,13.53 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,13.531,fee schedule,""
"MIDAZOLAM HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J2250,00409230505,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,4.06,fee schedule,""
"MIDAZOLAM HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J2250,00409230517,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,4.06,fee schedule,""
"MIDAZOLAM HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J2250,00409230516,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,4.06,fee schedule,""
"MIDAZOLAM HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J2250,00409230504,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.80 ,4.06 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,4.06,fee schedule,""
"EPTIFIBATIDE 75 MG/100ML IV SOLN",0250,J1327,67457063110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,253.80 ,177.66 ,Aetna,"AETNA",39.82,191,fee schedule,999999999,12.5,177.66,fee schedule,""
"ACYCLOVIR SODIUM 50 MG/ML IV SOLN",0250,J0133,55150015410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,14.77 ,10.34 ,Aetna,"AETNA",0.11,191,fee schedule,999999999,0.05,10.339,fee schedule,""
"DEXAMETHASONE 0.5 MG/5ML PO ELIX",0250,J8540,64980050924,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,177.75 ,124.43 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.08,124.425,fee schedule,""
"CANDESARTAN CILEXETIL 8 MG PO TABS",0250,A9270,49884065909,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.86 ,4.80 ,Aetna,"AETNA",3.09,45,percent of total billed charges,999999999,0.03087,4.802,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CANDESARTAN CILEXETIL 16 MG PO TABS",0250,A9270,49884066009,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.86 ,4.80 ,Aetna,"AETNA",3.09,45,percent of total billed charges,999999999,0.03087,4.802,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 1 MG PO TABS",0250,A9270,00054817425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 4 MG PO TABS",0250,J8540,00904726661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,6.66 ,4.66 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.08,4.662,fee schedule,""
"SODIUM METABISULFITE POWD",0250,,38779078705,RC,,NDC,FACILITY,OUTPATIENT,100,GR,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 6 MG PO TABS",0250,A9270,00054418625,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.93 ,6.25 ,Aetna,"AETNA",4.02,45,percent of total billed charges,999999999,0.03087,6.251,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST PLUS PO LIQD",0250,,43900093139,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,8.30 ,5.81 ,Aetna,"AETNA",3.74,45,percent of total billed charges,999999999,1.5,5.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST PLUS PO LIQD",0250,,43900093239,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,8.30 ,5.81 ,Aetna,"AETNA",3.74,45,percent of total billed charges,999999999,1.5,5.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST PLUS PO LIQD",0250,,43900093338,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,5.81,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN",0250,A9270,24208072002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,229.38 ,160.57 ,Aetna,"AETNA",103.22,45,percent of total billed charges,999999999,0.03087,160.566,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 4 % EX CREA",0250,,00496088205,RC,,NDC,FACILITY,OUTPATIENT,5,GR,,20.09 ,14.06 ,Aetna,"AETNA",9.04,45,percent of total billed charges,999999999,6.027,14.063,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CITALOPRAM HYDROBROMIDE 40 MG PO TABS",0250,A9270,57664050988,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CITALOPRAM HYDROBROMIDE 40 MG PO TABS",0250,A9270,00378623301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 40 % IV SOLN",0250,,00409793719,RC,,NDC,FACILITY,OUTPATIENT,60,ML,,5.04 ,3.53 ,Aetna,"AETNA",2.27,45,percent of total billed charges,999999999,1.512,3.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 50 % IV SOLN",0250,,00409664802,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,7.98,56.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 50 % IV SOLN",0250,,00409751716,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,81.00 ,56.70 ,Aetna,"AETNA",36.45,45,percent of total billed charges,999999999,7.98,56.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 50 % IV SOLN",0250,,00409664816,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,26.60 ,18.62 ,Aetna,"AETNA",11.97,45,percent of total billed charges,999999999,7.98,56.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 70 % IV SOLN",0250,,00338071906,RC,,NDC,FACILITY,OUTPATIENT,2000,ML,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLIXIMAB 100 MG IV SOLR",0250,J1745,57894003001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3415.86 ,2391.10 ,Aetna,"AETNA",60.49,191,fee schedule,999999999,32.161,2391.102,fee schedule,""
"ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS",0250,,00173067502,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,44.76 ,31.33 ,Aetna,"AETNA",20.14,45,percent of total billed charges,999999999,13.428,31.332,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEFLUNOMIDE 10 MG PO TABS",0250,A9270,23155004303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEFLUNOMIDE 20 MG PO TABS",0250,A9270,23155004403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.06 ,3.54 ,Aetna,"AETNA",2.28,45,percent of total billed charges,999999999,0.03087,3.542,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EFAVIRENZ 200 MG PO CAPS",0250,A9270,00056047492,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR",0250,J7519,71288080321,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,127.38 ,89.17 ,Aetna,"AETNA",1.36,191,fee schedule,999999999,0.727,89.166,fee schedule,""
"DIAZEPAM 5 MG/ML INJ SOLN",0250,J3360,69339013603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,19.95 ,13.97 ,Aetna,"AETNA",12.49,191,fee schedule,999999999,5.25,13.965,fee schedule,""
"DIAZEPAM 5 MG/ML INJ SOLN",0250,J3360,69339013634,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,19.95 ,13.97 ,Aetna,"AETNA",12.49,191,fee schedule,999999999,5.25,13.965,fee schedule,""
"DIAZEPAM 1 MG/ML PO SOLN",0250,A9270,00904711741,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,24.50 ,17.15 ,Aetna,"AETNA",11.03,45,percent of total billed charges,999999999,0.03087,17.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIAZEPAM 1 MG/ML PO SOLN",0250,A9270,00904711793,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,24.29 ,17.00 ,Aetna,"AETNA",10.93,45,percent of total billed charges,999999999,0.03087,17.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIAZEPAM 2 MG PO TABS",0250,A9270,51079028401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIAZEPAM 2 MG PO TABS",0250,A9270,51079028420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIAZEPAM 5 MG PO TABS",0250,A9270,51079028501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIAZEPAM 5 MG PO TABS",0250,A9270,51079028520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM ALUM POWD",0250,A9270,24357030030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,361.02 ,252.71 ,Aetna,"AETNA",162.46,45,percent of total billed charges,999999999,0.03087,252.714,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEVIRAPINE 50 MG/5ML PO SUSP",0250,A9270,65862005724,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,0.03087,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DICYCLOMINE HCL 10 MG/ML IM SOLN",0250,J0500,00641617301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,46.54 ,32.58 ,Aetna,"AETNA",47.73,191,fee schedule,999999999,13.962,47.7309,fee schedule,""
"DICYCLOMINE HCL 10 MG/ML IM SOLN",0250,J0500,00641617310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,46.54 ,32.58 ,Aetna,"AETNA",47.73,191,fee schedule,999999999,13.962,47.7309,fee schedule,""
"MIDAZOLAM HCL 2 MG/ML PO SYRP",0250,A9270,68094076259,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.81 ,8.27 ,Aetna,"AETNA",5.31,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIDAZOLAM HCL 2 MG/ML PO SYRP",0250,A9270,68094076262,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIDAZOLAM HCL 2 MG/ML PO SYRP",0250,A9270,68094076459,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,6.96 ,4.87 ,Aetna,"AETNA",3.13,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DICYCLOMINE HCL 10 MG PO CAPS",0250,A9270,00904698761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DICYCLOMINE HCL 20 MG PO TABS",0250,A9270,00904698861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS",0250,A9270,60687062201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG PO TABS",0250,A9270,60687062211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE MONONITRATE ER 60 MG PO TB24",0250,A9270,62175011937,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TELMISARTAN 40 MG PO TABS",0250,A9270,00378292193,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TELMISARTAN 80 MG PO TABS",0250,A9270,00378292293,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEUPROLIDE ACETATE 1 MG/0.2ML INJ KIT",0250,J9218,00781400332,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12500.00 ,8750.00 ,Aetna,"AETNA",21.05,191,fee schedule,999999999,7.88,8750,fee schedule,""
"HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN",0250,A9270,51672300701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,635.82 ,445.07 ,Aetna,"AETNA",286.12,45,percent of total billed charges,999999999,0.03087,445.074,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LAMIVUDINE 100 MG PO TABS",0250,A9270,00173066200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,91.49 ,64.04 ,Aetna,"AETNA",41.17,45,percent of total billed charges,999999999,0.03087,64.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIGOXIN 0.25 MG/ML INJ SOLN",0250,J1160,00781305995,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",17.30,191,fee schedule,999999999,1.5,20.58,fee schedule,""
"DIGOXIN 0.25 MG/ML INJ SOLN",0250,J1160,00781305972,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",17.30,191,fee schedule,999999999,1.5,20.58,fee schedule,""
"OCTREOTIDE ACETATE 20 MG IM KIT",0250,J2353,00078081881,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12009.78 ,8406.85 ,Aetna,"AETNA",402.17,191,fee schedule,999999999,206.96,8406.846,fee schedule,""
"OCTREOTIDE ACETATE 30 MG IM KIT",0250,J2353,00078082581,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,17983.74 ,12588.62 ,Aetna,"AETNA",402.17,191,fee schedule,999999999,206.96,12588.618,fee schedule,""
"ABACAVIR SULFATE 300 MG PO TABS",0250,A9270,51079020401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,50.75 ,35.53 ,Aetna,"AETNA",22.84,45,percent of total billed charges,999999999,0.03087,38.556,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ABACAVIR SULFATE 300 MG PO TABS",0250,A9270,51079020406,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,55.08 ,38.56 ,Aetna,"AETNA",24.79,45,percent of total billed charges,999999999,0.03087,38.556,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIGOXIN 125 MCG PO TABS",0250,A9270,70954020110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIGOXIN 250 MCG PO TABS",0250,A9270,70954020210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYBUTYNIN CHLORIDE ER 5 MG PO TB24",0250,A9270,27241015504,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYBUTYNIN CHLORIDE ER 10 MG PO TB24",0250,A9270,27241015604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CILOSTAZOL 100 MG PO TABS",0250,A9270,60505252201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CELECOXIB 100 MG PO CAPS",0250,A9270,00904650261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.12 ,4.28 ,Aetna,"AETNA",2.75,45,percent of total billed charges,999999999,0.03087,4.284,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CELECOXIB 200 MG PO CAPS",0250,A9270,69097042112,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE MONONITRATE ER 30 MG PO TB24",0250,A9270,00904644961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D3 (CHOLECALCIFEROL) 10 MCG (400 UNIT) PO TABS",0250,A9270,00904582360,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIMOLOL MALEATE 0.25 % OP SOLG",0250,,24208081825,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,885.96 ,620.17 ,Aetna,"AETNA",398.68,45,percent of total billed charges,999999999,265.788,620.172,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIMOLOL MALEATE 0.5 % OP SOLG",0250,,43598074811,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,989.85 ,692.90 ,Aetna,"AETNA",445.43,45,percent of total billed charges,999999999,296.955,692.895,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR",0250,J7511,58468008001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,3198.48 ,2238.94 ,Aetna,"AETNA",1772.37,191,fee schedule,999999999,902.62,2238.936,fee schedule,""
"DIMERCAPTOSUCCINIC ACID POWD",0250,,38779078003,RC,,NDC,FACILITY,OUTPATIENT,5,GR,,221.40 ,154.98 ,Aetna,"AETNA",99.63,45,percent of total billed charges,999999999,66.42,154.98,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MODAFINIL 100 MG PO TABS",0250,A9270,62332038530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MODAFINIL 200 MG PO TABS",0250,A9270,49884053511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,159.39 ,111.57 ,Aetna,"AETNA",71.73,45,percent of total billed charges,999999999,0.03087,111.573,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 30 MG PO TABS",0250,A9270,60687071701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 30 MG PO TABS",0250,A9270,60687071711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 60 MG PO TABS",0250,A9270,50228048201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 90 MG PO TABS",0250,A9270,50228048301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TACROLIMUS 0.5 MG PO CAPS",0250,J7507,00904662361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,6.22 ,4.35 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.236,4.354,fee schedule,""
"LEVALBUTEROL HCL 0.63 MG/3ML INH NEBU",0250,J7614,00093414656,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.04,3.5,fee schedule,""
"LEVALBUTEROL HCL 0.63 MG/3ML INH NEBU",0250,J7614,00093414619,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.04,3.5,fee schedule,""
"LEVALBUTEROL HCL 1.25 MG/3ML INH NEBU",0250,J7614,00093414856,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,8.30 ,5.81 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.04,5.81,fee schedule,""
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN",0250,J2916,00143957001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,66.05 ,46.24 ,Aetna,"AETNA",4.16,191,fee schedule,999999999,1.95,46.235,fee schedule,""
"NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN",0250,J2916,00143957010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,56.74 ,39.72 ,Aetna,"AETNA",4.16,191,fee schedule,999999999,1.95,46.235,fee schedule,""
"ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% INH NEBU",0250,J7613,00487950103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.08,191,fee schedule,999999999,0.03,3.5,fee schedule,""
"MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR",0250,J7517,00527516082,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,58.59 ,41.01 ,Aetna,"AETNA",0.38,191,fee schedule,999999999,0.188,41.013,fee schedule,""
"DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN",0250,J1200,63323066400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.804,4.123,fee schedule,""
"DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN",0250,J1200,63323066401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.89 ,4.12 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.804,4.123,fee schedule,""
"ALBUTEROL SULFATE (5 MG/ML) 0.5% INH NEBU",0250,J7611,00487990130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.31,191,fee schedule,999999999,0.12,3.5,fee schedule,""
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX",0250,,00121048905,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,26.53 ,18.57 ,Aetna,"AETNA",11.94,45,percent of total billed charges,999999999,7.959,18.571,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX",0250,,00121048900,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,26.53 ,18.57 ,Aetna,"AETNA",11.94,45,percent of total billed charges,999999999,7.959,18.571,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN HCL 250 MG PO TABS",0250,A9270,65862007601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN HCL 500 MG PO TABS",0250,A9270,00904637861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN HCL 750 MG PO TABS",0250,A9270,65862007850,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN",0250,J2354,63323037601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,12.27 ,8.59 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,1.12,8.589,fee schedule,""
"OCTREOTIDE ACETATE 100 MCG/ML INJ SOLN",0250,J2354,63323037600,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,12.27 ,8.59 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,1.12,8.589,fee schedule,""
"OCTREOTIDE ACETATE 200 MCG/ML INJ SOLN",0250,J2354,63323037805,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,9.99 ,6.99 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,1.12,6.993,fee schedule,""
"OCTREOTIDE ACETATE 500 MCG/ML INJ SOLN",0250,J2354,63323037701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,14.00 ,9.80 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,1.12,9.8,fee schedule,""
"OCTREOTIDE ACETATE 1000 MCG/ML INJ SOLN",0250,J2354,63323037905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,11.85 ,8.30 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,1.12,8.295,fee schedule,""
"DIPHENHYDRAMINE HCL 25 MG PO TABS",0250,A9270,68094001859,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENHYDRAMINE HCL 25 MG PO TABS",0250,A9270,68094001861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IODINE STRONG (LUGOLS) 5 % PO SOLN",0250,,48433023015,RC,,NDC,FACILITY,OUTPATIENT,14,ML,,236.04 ,165.23 ,Aetna,"AETNA",106.22,45,percent of total billed charges,999999999,70.812,165.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD",0250,A9270,99999040899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,33.32 ,23.32 ,Aetna,"AETNA",14.99,45,percent of total billed charges,999999999,0.03087,23.324,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD",0250,A9270,00054319446,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,28.56 ,19.99 ,Aetna,"AETNA",12.85,45,percent of total billed charges,999999999,0.03087,23.324,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS",0250,A9270,69315091001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL ER 120 MG PO CP24",0250,A9270,51079091701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,24.61 ,17.23 ,Aetna,"AETNA",11.07,45,percent of total billed charges,999999999,0.03087,19.691,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL ER 120 MG PO CP24",0250,A9270,51079091720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,28.13 ,19.69 ,Aetna,"AETNA",12.66,45,percent of total billed charges,999999999,0.03087,19.691,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN 400 MG/5ML PO SUSR",0250,A9270,99999034699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN 400 MG/5ML PO SUSR",0250,A9270,00093416173,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPYRIDAMOLE 25 MG PO TABS",0250,A9270,68382018701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPYRIDAMOLE 50 MG PO TABS",0250,A9270,64980013401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.01 ,5.61 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.607,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPYRIDAMOLE 75 MG PO TABS",0250,A9270,68382018901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.27 ,3.69 ,Aetna,"AETNA",2.37,45,percent of total billed charges,999999999,0.03087,3.689,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DISOPYRAMIDE PHOSPHATE 100 MG PO CAPS",0250,A9270,51862009501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBUTEROL SULFATE 4 MG PO TABS",0250,A9270,64980044301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DISULFIRAM 250 MG PO TABS",0250,A9270,51285052302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,49.72 ,34.80 ,Aetna,"AETNA",22.37,45,percent of total billed charges,999999999,0.03087,34.804,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DISULFIRAM 250 MG PO TABS",0250,A9270,00093503501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,21.71 ,15.20 ,Aetna,"AETNA",9.77,45,percent of total billed charges,999999999,0.03087,34.804,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK",0250,A9270,00904693181,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYETHYLENE GLYCOL 3350 17 G PO PACK",0250,A9270,00904693186,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORAMPHENICOL SOD SUCCINATE 1 G IV SOLR",0250,J0720,63323001115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,220.24 ,154.17 ,Aetna,"AETNA",111.51,191,fee schedule,999999999,35.99,154.168,fee schedule,""
"DIVALPROEX SODIUM 250 MG PO TBEC",0250,A9270,00832712301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIVALPROEX SODIUM 250 MG PO TBEC",0250,A9270,00832712389,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RISPERIDONE 0.5 MG PO TABS",0250,A9270,00904736161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PIOGLITAZONE HCL 15 MG PO TABS",0250,A9270,57237021930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PIOGLITAZONE HCL 30 MG PO TABS",0250,A9270,57237022090,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIVALPROEX SODIUM 500 MG PO TBEC",0250,A9270,00832712401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PIOGLITAZONE HCL 45 MG PO TABS",0250,A9270,57237022190,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TROPHAMINE 10 % IV SOLN",0250,,00264193310,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,249.00 ,174.30 ,Aetna,"AETNA",112.05,45,percent of total billed charges,999999999,74.7,174.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IVERMECTIN 3 MG PO TABS",0250,A9270,00006003220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.32 ,21.22 ,Aetna,"AETNA",13.64,45,percent of total billed charges,999999999,0.03087,21.224,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TEMOZOLOMIDE 5 MG PO CAPS",0250,J8700,65162080114,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,16.43 ,11.50 ,Aetna,"AETNA",0.36,191,fee schedule,999999999,0.19,11.501,fee schedule,""
"TEMOZOLOMIDE 20 MG PO CAPS",0250,J8700,65162080214,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,31.28 ,21.90 ,Aetna,"AETNA",0.36,191,fee schedule,999999999,0.19,21.896,fee schedule,""
"TEMOZOLOMIDE 100 MG PO CAPS",0250,J8700,65162080351,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,70.19 ,49.13 ,Aetna,"AETNA",0.36,191,fee schedule,999999999,0.19,49.133,fee schedule,""
"DOPAMINE HCL 40 MG/ML IV SOLN",0250,J1265,00143925401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,33.60 ,23.52 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.63,23.52,fee schedule,""
"DOPAMINE HCL 40 MG/ML IV SOLN",0250,J1265,00143925425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,33.60 ,23.52 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.63,23.52,fee schedule,""
"DOXAPRAM HCL 20 MG/ML IV SOLN",0250,,00641601801,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,282.48 ,197.74 ,Aetna,"AETNA",127.12,45,percent of total billed charges,999999999,84.744,197.736,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXEPIN HCL 10 MG PO CAPS",0250,A9270,00904705261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXEPIN HCL 100 MG PO CAPS",0250,A9270,62332064031,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXEPIN HCL 25 MG PO CAPS",0250,A9270,00904705361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXEPIN HCL 50 MG PO CAPS",0250,A9270,00904705461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXORUBICIN HCL 2 MG/ML IV SOLN",0250,J9000,63323088330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,61.95 ,43.37 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,247.8,fee schedule,""
"DOXORUBICIN HCL 2 MG/ML IV SOLN",0250,J9000,00069303420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,278.40 ,194.88 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,247.8,fee schedule,""
"DOXORUBICIN HCL 2 MG/ML IV SOLN",0250,J9000,62756082740,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,242.40 ,169.68 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,247.8,fee schedule,""
"DOXORUBICIN HCL 2 MG/ML IV SOLN",0250,J9000,00069403701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,354.00 ,247.80 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,247.8,fee schedule,""
"DOXORUBICIN HCL 2 MG/ML IV SOLN",0250,J9000,45963073357,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,113.88 ,79.72 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,247.8,fee schedule,""
"DOXORUBICIN HCL 50 MG IV SOLR",0250,J9000,67457043650,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2565.28 ,1795.70 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,1795.696,fee schedule,""
"DOXYCYCLINE HYCLATE 100 MG IV SOLR",0250,,68382091001,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,73.91 ,51.74 ,Aetna,"AETNA",33.26,45,percent of total billed charges,999999999,22.173,51.737,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXYCYCLINE HYCLATE 100 MG IV SOLR",0250,,68382091010,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,73.91 ,51.74 ,Aetna,"AETNA",33.26,45,percent of total billed charges,999999999,22.173,51.737,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PANTOPRAZOLE SODIUM 40 MG IV SOLR",0250,C9113,71288060010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,13.48 ,9.44 ,Aetna,"AETNA",10.43,191,fee schedule,999999999,3.37,10.4286,fee schedule,""
"PANTOPRAZOLE SODIUM 40 MG IV SOLR",0250,C9113,71288060011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,40,ME,,13.48 ,9.44 ,Aetna,"AETNA",10.43,191,fee schedule,999999999,3.37,10.4286,fee schedule,""
"QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR",0250,J2770,61570026010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,2193.39 ,1535.37 ,Aetna,"AETNA",1068.09,191,fee schedule,999999999,0.01,1535.373,fee schedule,""
"CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR",0250,A9270,51079092301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR",0250,A9270,51079092320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.23 ,3.66 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DROPERIDOL 2.5 MG/ML INJ SOLN",0250,J1790,00517970225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,6.21 ,4.35 ,Aetna,"AETNA",21.33,191,fee schedule,999999999,1.863,21.3347,fee schedule,""
"DROPERIDOL 2.5 MG/ML INJ SOLN",0250,J1790,00517970201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,6.21 ,4.35 ,Aetna,"AETNA",21.33,191,fee schedule,999999999,1.863,21.3347,fee schedule,""
"OSELTAMIVIR PHOSPHATE 75 MG PO CAPS",0250,A9270,70710101002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,67.84 ,47.49 ,Aetna,"AETNA",30.53,45,percent of total billed charges,999999999,0.03087,47.488,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENTACAPONE 200 MG PO TABS",0250,A9270,65862065401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVETIRACETAM 250 MG PO TABS",0250,A9270,00904712361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVETIRACETAM 500 MG PO TABS",0250,A9270,00904712461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOFETILIDE 125 MCG PO CAPS",0250,A9270,47335006186,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOFETILIDE 250 MCG PO CAPS",0250,A9270,47335006286,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOFETILIDE 500 MCG PO CAPS",0250,A9270,69452013317,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHACHOLINE CHLORIDE 100 MG INH SOLR",0250,J7674,64281010000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,463.69 ,324.58 ,Aetna,"AETNA",2.14,191,fee schedule,999999999,0.81,324.583,fee schedule,""
"PREDNISOLONE ACETATE 0.12 % OP SUSP",0250,A9270,11980017405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,896.10 ,627.27 ,Aetna,"AETNA",403.25,45,percent of total billed charges,999999999,0.03087,627.27,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUSPIRONE HCL 30 MG PO TABS",0250,A9270,68382018314,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PORACTANT ALFA 80 MG/ML INTRATRACHEAL SUSP",0250,,10122051001,RC,,NDC,FACILITY,OUTPATIENT,1.5,ML,,2478.75 ,1735.13 ,Aetna,"AETNA",1115.44,45,percent of total billed charges,999999999,743.625,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PORACTANT ALFA 80 MG/ML INTRATRACHEAL SUSP",0250,,10122051003,RC,,NDC,FACILITY,OUTPATIENT,1.5,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,743.625,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXCARBAZEPINE 150 MG PO TABS",0250,A9270,00904726261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENOFIBRATE MICRONIZED 134 MG PO CAPS",0250,A9270,62332008531,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.4 MG/SPRAY TL SOLN",0250,A9270,24338030065,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,1021.45 ,715.02 ,Aetna,"AETNA",459.65,45,percent of total billed charges,999999999,0.03087,715.015,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHARCOAL ACTIVATED PO LIQD",0250,A9270,00574052174,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,90.72 ,63.50 ,Aetna,"AETNA",40.82,45,percent of total billed charges,999999999,0.03087,63.504,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RISEDRONATE SODIUM 5 MG PO TABS",0250,A9270,33342010707,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,19.44 ,13.61 ,Aetna,"AETNA",8.75,45,percent of total billed charges,999999999,0.03087,13.608,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONIDINE HCL (ANALGESIA) 500 MCG/ML EPID SOLN",0250,J0735,63323042710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,549.18 ,384.43 ,Aetna,"AETNA",32.51,191,fee schedule,999999999,18.47,384.426,fee schedule,""
"KCL IN DEXTROSE-NACL 20-5-0.225 MEQ/L-%-% IV SOLN",0250,,00409790109,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,12.6,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR",0250,A9270,59651001890,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIACIN ER (ANTIHYPERLIPIDEMIC) 750 MG PO TBCR",0250,A9270,00074307990,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,48.64 ,34.05 ,Aetna,"AETNA",21.89,45,percent of total billed charges,999999999,0.03087,34.048,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MONTELUKAST SODIUM 4 MG PO CHEW",0250,A9270,00006071131,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,35.39 ,24.77 ,Aetna,"AETNA",15.93,45,percent of total billed charges,999999999,0.03087,24.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MONTELUKAST SODIUM 4 MG PO CHEW",0250,A9270,00603465316,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.42 ,4.49 ,Aetna,"AETNA",2.89,45,percent of total billed charges,999999999,0.03087,24.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFUROXIME SODIUM 1.5 G IV SOLR",0250,J0697,25021011920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,750,ME,,22.68 ,15.88 ,Aetna,"AETNA",3.61,191,fee schedule,999999999,1.87,15.876,fee schedule,""
"CEFEPIME HCL 2 G IV SOLR",0250,J0692,44567024110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,31.16 ,21.81 ,Aetna,"AETNA",2.56,191,fee schedule,999999999,1.23,21.812,fee schedule,""
"MINERAL OIL LIGHT OIL",0250,,63323025410,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,61.25 ,42.88 ,Aetna,"AETNA",27.56,45,percent of total billed charges,999999999,18.375,42.875,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 50 MG/ML IV SOLN",0250,J2270,00409113403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,78.24 ,54.77 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,116.34,fee schedule,""
"MORPHINE SULFATE 50 MG/ML IV SOLN",0250,J2270,00409113405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,166.20 ,116.34 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,116.34,fee schedule,""
"PENTAMIDINE ISETHIONATE 300 MG INJ SOLR",0250,,39822305002,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,335.20 ,234.64 ,Aetna,"AETNA",150.84,45,percent of total billed charges,999999999,100.56,234.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ",0250,Q2050,47335004940,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,966.30 ,676.41 ,Aetna,"AETNA",219.54,191,fee schedule,999999999,85.484,2037.07,fee schedule,""
"DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ",0250,Q2050,00338006701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2910.10 ,2037.07 ,Aetna,"AETNA",219.54,191,fee schedule,999999999,85.484,2037.07,fee schedule,""
"ESTRADIOL 0.05 MG/24HR TD PTTW",0250,A9270,65162099304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,49.23 ,34.46 ,Aetna,"AETNA",22.15,45,percent of total billed charges,999999999,0.03087,34.461,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.05 MG/24HR TD PTTW",0250,A9270,65162099308,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,49.23 ,34.46 ,Aetna,"AETNA",22.15,45,percent of total billed charges,999999999,0.03087,34.461,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.1 MG/24HR TD PTTW",0250,A9270,65162099704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,52.05 ,36.44 ,Aetna,"AETNA",23.42,45,percent of total billed charges,999999999,0.03087,36.435,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.1 MG/24HR TD PTTW",0250,A9270,65162099708,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,52.05 ,36.44 ,Aetna,"AETNA",23.42,45,percent of total billed charges,999999999,0.03087,36.435,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.025 MG/24HR TD PTWK",0250,A9270,00781711954,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,77.73 ,54.41 ,Aetna,"AETNA",34.98,45,percent of total billed charges,999999999,0.03087,54.411,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.025 MG/24HR TD PTWK",0250,A9270,00781711958,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,77.73 ,54.41 ,Aetna,"AETNA",34.98,45,percent of total billed charges,999999999,0.03087,54.411,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DINOPROSTONE 10 MG VA INST",0250,A9270,55566280001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2251.75 ,1576.23 ,Aetna,"AETNA",1013.29,45,percent of total billed charges,999999999,0.03087,1576.225,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.1 MG/HR TD PT24",0250,A9270,00378910293,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.1 MG/HR TD PT24",0250,A9270,00378910216,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.2 MG/HR TD PT24",0250,A9270,00378910493,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.2 MG/HR TD PT24",0250,A9270,00378910416,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.3 MG/HR TD PT24",0250,A9270,50742051530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,296.04 ,207.23 ,Aetna,"AETNA",133.22,45,percent of total billed charges,999999999,0.03087,207.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.3 MG/HR TD PT24",0250,A9270,50742051501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,296.04 ,207.23 ,Aetna,"AETNA",133.22,45,percent of total billed charges,999999999,0.03087,207.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.4 MG/HR TD PT24",0250,A9270,00378911293,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.40 ,3.78 ,Aetna,"AETNA",2.43,45,percent of total billed charges,999999999,0.03087,3.78,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.4 MG/HR TD PT24",0250,A9270,00378911216,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.40 ,3.78 ,Aetna,"AETNA",2.43,45,percent of total billed charges,999999999,0.03087,3.78,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FELODIPINE ER 2.5 MG PO TB24",0250,A9270,13668013201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FELODIPINE ER 5 MG PO TB24",0250,A9270,13668013301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FELODIPINE ER 10 MG PO TB24",0250,A9270,51079046801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.91 ,7.64 ,Aetna,"AETNA",4.91,45,percent of total billed charges,999999999,0.03087,11.151,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FELODIPINE ER 10 MG PO TB24",0250,A9270,51079046820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.93 ,11.15 ,Aetna,"AETNA",7.17,45,percent of total billed charges,999999999,0.03087,11.151,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORATADINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12",0250,A9270,45802012265,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.22 ,4.35 ,Aetna,"AETNA",2.80,45,percent of total billed charges,999999999,0.03087,4.354,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBAMAZEPINE ER 100 MG PO TB12",0250,A9270,51672412301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.51 ,3.86 ,Aetna,"AETNA",2.48,45,percent of total billed charges,999999999,0.03087,3.857,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBAMAZEPINE ER 400 MG PO TB12",0250,A9270,60687059411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,34.38 ,24.07 ,Aetna,"AETNA",15.47,45,percent of total billed charges,999999999,0.03087,24.066,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBAMAZEPINE ER 400 MG PO TB12",0250,A9270,60687059421,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.94 ,6.26 ,Aetna,"AETNA",4.02,45,percent of total billed charges,999999999,0.03087,24.066,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12",0250,A9270,68462040560,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.16 ,4.31 ,Aetna,"AETNA",2.77,45,percent of total billed charges,999999999,0.03087,4.312,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24",0250,A9270,50742026101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUORESCEIN SODIUM 0.6 MG OP STRP",0250,,17478040303,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUORESCEIN SODIUM 1 MG OP STRP",0250,,17238090030,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUORESCEIN SODIUM 1 MG OP STRP",0250,,17238090099,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMEPRAZOLE 20 MG PO CPDR",0250,A9270,00904691761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SCOPOLAMINE 1 MG/3DAYS TD PT72",0250,A9270,50742050524,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,44.37 ,31.06 ,Aetna,"AETNA",19.97,45,percent of total billed charges,999999999,0.03087,31.059,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONDANSETRON 4 MG PO TBDP",0250,J8597,00378773293,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,7.22 ,5.05 ,Aetna,"AETNA",3.25,45,percent of total billed charges,999999999,0,5.054,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONDANSETRON 8 MG PO TBDP",0250,J8597,65862039110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,8,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN",0250,,24208034205,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,935.80 ,655.06 ,Aetna,"AETNA",421.11,45,percent of total billed charges,999999999,280.74,655.06,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZONISAMIDE 100 MG PO CAPS",0250,A9270,50268081615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZONISAMIDE 100 MG PO CAPS",0250,A9270,50268081611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENLAFAXINE HCL ER 37.5 MG PO CP24",0250,A9270,00904707561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VENLAFAXINE HCL ER 75 MG PO CP24",0250,A9270,00904707761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE 7 MG/24HR TD PT24",0250,A9270,00536589488,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.31 ,8.62 ,Aetna,"AETNA",5.54,45,percent of total billed charges,999999999,0.03087,8.617,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE 14 MG/24HR TD PT24",0250,A9270,00536589588,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.10 ,8.47 ,Aetna,"AETNA",5.45,45,percent of total billed charges,999999999,0.03087,8.47,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE 14 MG/24HR TD PT24",0250,A9270,60505706200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.10 ,8.47 ,Aetna,"AETNA",5.45,45,percent of total billed charges,999999999,0.03087,8.47,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICOTINE 21 MG/24HR TD PT24",0250,A9270,00536589688,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.32 ,7.22 ,Aetna,"AETNA",4.64,45,percent of total billed charges,999999999,0.03087,7.224,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN",0250,,99999051599,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN",0250,,00121495015,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,36.54 ,25.58 ,Aetna,"AETNA",16.44,45,percent of total billed charges,999999999,1.5,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN",0250,,00121495040,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,36.54 ,25.58 ,Aetna,"AETNA",16.44,45,percent of total billed charges,999999999,1.5,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE VISCOUS HCL 2 % MT SOLN",0250,,00054350049,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,44.10 ,30.87 ,Aetna,"AETNA",19.85,45,percent of total billed charges,999999999,1.5,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 25 MCG/HR TD PT72",0250,A9270,47781042447,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,22.69 ,15.88 ,Aetna,"AETNA",10.21,45,percent of total billed charges,999999999,0.03087,15.883,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 25 MCG/HR TD PT72",0250,A9270,47781042411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,22.69 ,15.88 ,Aetna,"AETNA",10.21,45,percent of total billed charges,999999999,0.03087,15.883,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 50 MCG/HR TD PT72",0250,A9270,47781042647,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,43.60 ,30.52 ,Aetna,"AETNA",19.62,45,percent of total billed charges,999999999,0.03087,30.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 50 MCG/HR TD PT72",0250,A9270,47781042611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,43.60 ,30.52 ,Aetna,"AETNA",19.62,45,percent of total billed charges,999999999,0.03087,30.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 75 MCG/HR TD PT72",0250,A9270,47781042747,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,56.01 ,39.21 ,Aetna,"AETNA",25.20,45,percent of total billed charges,999999999,0.03087,39.207,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 75 MCG/HR TD PT72",0250,A9270,47781042711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,56.01 ,39.21 ,Aetna,"AETNA",25.20,45,percent of total billed charges,999999999,0.03087,39.207,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 100 MCG/HR TD PT72",0250,A9270,47781042847,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,66.68 ,46.68 ,Aetna,"AETNA",30.01,45,percent of total billed charges,999999999,0.03087,46.676,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 100 MCG/HR TD PT72",0250,A9270,47781042811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,66.68 ,46.68 ,Aetna,"AETNA",30.01,45,percent of total billed charges,999999999,0.03087,46.676,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBOXYMETHYLCELLULOSE SODIUM 0.5 % OP SOLN",0250,A9270,50268006815,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,60.17 ,42.12 ,Aetna,"AETNA",27.08,45,percent of total billed charges,999999999,0.03087,42.119,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYVINYL ALCOHOL 1.4 % OP SOLN",0250,A9270,17478006012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,53.87 ,37.71 ,Aetna,"AETNA",24.24,45,percent of total billed charges,999999999,0.03087,37.709,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP",0250,A9270,46287000660,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,148.68 ,104.08 ,Aetna,"AETNA",66.91,45,percent of total billed charges,999999999,0.03087,104.076,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BAZA ANTIFUNGAL 2 % EX CREA",0250,A9270,11701004523,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,43.89 ,30.72 ,Aetna,"AETNA",19.75,45,percent of total billed charges,999999999,0.03087,30.723,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GELATIN ABSORBABLE 12-7 MM EX MISC",0250,,00009031508,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.37 ,21.26 ,Aetna,"AETNA",13.67,45,percent of total billed charges,999999999,9.111,21.259,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GELATIN ADSORBABLE OP FILM",0250,,00009029703,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,1099.18 ,769.43 ,Aetna,"AETNA",494.63,45,percent of total billed charges,999999999,329.754,769.426,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS SULFATE-C-FA ER 105-500-0.8 MG PO TBCR",0250,A9270,64980017303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.23 ,3.66 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.661,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLANZAPINE 5 MG PO TBDP",0250,A9270,33342008307,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 5 % EX PTCH",0250,,00591352511,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,18.45 ,12.92 ,Aetna,"AETNA",8.30,45,percent of total billed charges,999999999,3.912,12.915,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 5 % EX PTCH",0250,,00591352530,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.04 ,9.13 ,Aetna,"AETNA",5.87,45,percent of total billed charges,999999999,3.912,12.915,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LINEZOLID 600 MG PO TABS",0250,A9270,00904655304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.84 ,10.39 ,Aetna,"AETNA",6.68,45,percent of total billed charges,999999999,0.03087,10.388,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LINEZOLID 100 MG/5ML PO SUSR",0250,A9270,00009513601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,83.33 ,58.33 ,Aetna,"AETNA",37.50,45,percent of total billed charges,999999999,0.03087,58.331,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVASTIGMINE TARTRATE 1.5 MG PO CAPS",0250,A9270,55111035260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,21.161,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVASTIGMINE TARTRATE 1.5 MG PO CAPS",0250,A9270,00781261406,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,17.58 ,12.31 ,Aetna,"AETNA",7.91,45,percent of total billed charges,999999999,0.03087,21.161,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVASTIGMINE TARTRATE 1.5 MG PO CAPS",0250,A9270,00078032306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.23 ,21.16 ,Aetna,"AETNA",13.60,45,percent of total billed charges,999999999,0.03087,21.161,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COLESEVELAM HCL 625 MG PO TABS",0250,A9270,68462043318,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS",0250,A9270,60687041801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.05 MG/24HR TD PTWK",0250,A9270,00781713354,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,76.52 ,53.56 ,Aetna,"AETNA",34.43,45,percent of total billed charges,999999999,0.03087,62.573,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.05 MG/24HR TD PTWK",0250,A9270,00781713358,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,89.39 ,62.57 ,Aetna,"AETNA",40.23,45,percent of total billed charges,999999999,0.03087,62.573,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.1 MG/24HR TD PTWK",0250,A9270,00781710454,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,85.58 ,59.91 ,Aetna,"AETNA",38.51,45,percent of total billed charges,999999999,0.03087,59.906,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 0.1 MG/24HR TD PTWK",0250,A9270,00781710458,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,82.85 ,58.00 ,Aetna,"AETNA",37.28,45,percent of total billed charges,999999999,0.03087,59.906,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J0171,42023015925,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,21.00 ,14.70 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,16.534,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J0171,42023016801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,9.00 ,6.30 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,16.534,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J0171,42023015901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,23.62 ,16.53 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,16.534,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J0171,00517117101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,16.78 ,11.75 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,16.534,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN (WRAPPER)",0250,J0171,00517117110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,16.78 ,11.75 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,16.534,fee schedule,""
"TENECTEPLASE 50 MG IV KIT",0250,J3101,50242012047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12736.80 ,8915.76 ,Aetna,"AETNA",292.44,191,fee schedule,999999999,143.87,8915.76,fee schedule,""
"NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24",0250,A9270,68084059701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.02 ,4.91 ,Aetna,"AETNA",3.16,45,percent of total billed charges,999999999,0.03087,4.914,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24",0250,A9270,68084059711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.18 ,4.33 ,Aetna,"AETNA",2.78,45,percent of total billed charges,999999999,0.03087,4.914,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATORVASTATIN CALCIUM 80 MG PO TABS",0250,A9270,00904629304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUDESONIDE 0.25 MG/2ML INH SUSP",0250,J7626,00093681573,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,12.59 ,8.81 ,Aetna,"AETNA",2.29,191,fee schedule,999999999,0.88,8.813,fee schedule,""
"BUDESONIDE 0.25 MG/2ML INH SUSP",0250,J7626,00093681519,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,12.59 ,8.81 ,Aetna,"AETNA",2.29,191,fee schedule,999999999,0.88,8.813,fee schedule,""
"BUDESONIDE 0.5 MG/2ML INH SUSP",0250,J7626,60687052479,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,24.18 ,16.93 ,Aetna,"AETNA",2.29,191,fee schedule,999999999,0.88,22.498,fee schedule,""
"BUDESONIDE 0.5 MG/2ML INH SUSP",0250,J7626,60687052483,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,32.14 ,22.50 ,Aetna,"AETNA",2.29,191,fee schedule,999999999,0.88,22.498,fee schedule,""
"NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP",0250,,24208063562,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,256.56 ,179.59 ,Aetna,"AETNA",115.45,45,percent of total billed charges,999999999,76.968,179.592,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIVALPROEX SODIUM ER 500 MG PO TB24",0250,A9270,65162075710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCERIN LIQD",0250,A9270,00395103116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,141.90 ,99.33 ,Aetna,"AETNA",63.86,45,percent of total billed charges,999999999,0.03087,99.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYL SALICYLATE EX LIQD",0250,A9270,00395166792,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,ML,,53.28 ,37.30 ,Aetna,"AETNA",23.98,45,percent of total billed charges,999999999,0.03087,37.296,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP",0250,A9270,60687042945,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP",0250,A9270,60687042976,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOSPORINE MODIFIED 25 MG PO CAPS",0250,J7515,51862045847,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,5.73 ,4.01 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.66,4.011,fee schedule,""
"CYCLOSPORINE MODIFIED 25 MG PO CAPS",0250,J7515,51862045801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,5.73 ,4.01 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.66,4.011,fee schedule,""
"CYCLOSPORINE MODIFIED 100 MG PO CAPS",0250,J7502,51862046047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,20.03 ,14.02 ,Aetna,"AETNA",4.39,191,fee schedule,999999999,1.76,14.021,fee schedule,""
"CYCLOSPORINE MODIFIED 100 MG PO CAPS",0250,J7502,51862046001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,20.03 ,14.02 ,Aetna,"AETNA",4.39,191,fee schedule,999999999,1.76,14.021,fee schedule,""
"CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN",0250,J7502,00172731320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,9.00 ,6.30 ,Aetna,"AETNA",4.39,191,fee schedule,999999999,1.76,7.1001,fee schedule,""
"LEVOFLOXACIN 0.5 % OP SOLN",0250,,16571015050,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,449.94 ,314.96 ,Aetna,"AETNA",202.47,45,percent of total billed charges,999999999,134.982,314.958,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERYTHROMYCIN 5 MG/GM OP OINT",0250,,24208091019,RC,,NDC,FACILITY,OUTPATIENT,1,GR,,49.43 ,34.60 ,Aetna,"AETNA",22.24,45,percent of total billed charges,999999999,14.829,38.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERYTHROMYCIN 5 MG/GM OP OINT",0250,,24208091055,RC,,NDC,FACILITY,OUTPATIENT,1,GR,,54.46 ,38.12 ,Aetna,"AETNA",24.51,45,percent of total billed charges,999999999,14.829,38.122,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 15 MG PO TABS",0250,A9270,68084097501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.87 ,4.81 ,Aetna,"AETNA",3.09,45,percent of total billed charges,999999999,0.03087,4.809,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 15 MG PO TABS",0250,A9270,68084097511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.87 ,4.81 ,Aetna,"AETNA",3.09,45,percent of total billed charges,999999999,0.03087,4.809,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 30 MG PO TABS",0250,A9270,65162005110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERYTHROMYCIN BASE 250 MG PO TBEC",0250,A9270,69238147103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,32.40 ,22.68 ,Aetna,"AETNA",14.58,45,percent of total billed charges,999999999,0.03087,22.68,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARMUSTINE 100 MG IV SOLR",0250,J9050,23155026141,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,4582.77 ,3207.94 ,Aetna,"AETNA",536.56,191,fee schedule,999999999,271.465,3207.939,fee schedule,""
"DACTINOMYCIN 0.5 MG IV SOLR",0250,J9120,66993048983,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,2707.64 ,1895.35 ,Aetna,"AETNA",1046.30,191,fee schedule,999999999,557.4,1895.348,fee schedule,""
"LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN",0250,A9270,00074395646,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,78.00 ,54.60 ,Aetna,"AETNA",35.10,45,percent of total billed charges,999999999,0.03087,54.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 750 MG PO TABS",0250,A9270,00093729353,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 750 MG PO TABS",0250,A9270,65862053820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.40 ,3.78 ,Aetna,"AETNA",2.43,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOFLOXACIN 750 MG PO TABS",0250,A9270,00904635361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR",0250,A9270,60219150301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,100.45 ,70.32 ,Aetna,"AETNA",45.20,45,percent of total billed charges,999999999,0.03087,70.315,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METFORMIN HCL ER 500 MG PO TB24",0250,A9270,60687064001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METFORMIN HCL ER 500 MG PO TB24",0250,A9270,60687064011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR",0250,J1364,00409648201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,320.68 ,224.48 ,Aetna,"AETNA",148.69,191,fee schedule,999999999,38.436,224.476,fee schedule,""
"ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR",0250,J1364,00409647644,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,128.12 ,89.68 ,Aetna,"AETNA",148.69,191,fee schedule,999999999,38.436,224.476,fee schedule,""
"ALENDRONATE SODIUM 70 MG PO TABS",0250,A9270,69097022416,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARSENIC TRIOXIDE 10 MG/10ML IV SOLN",0250,J9017,63323063703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,303.90 ,212.73 ,Aetna,"AETNA",22.73,191,fee schedule,999999999,12.91,212.73,fee schedule,""
"ARSENIC TRIOXIDE 10 MG/10ML IV SOLN",0250,J9017,63323063710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,303.90 ,212.73 ,Aetna,"AETNA",22.73,191,fee schedule,999999999,12.91,212.73,fee schedule,""
"ARSENIC TRIOXIDE 10 MG/10ML IV SOLN",0250,J9017,14789060010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,279.36 ,195.55 ,Aetna,"AETNA",22.73,191,fee schedule,999999999,12.91,212.73,fee schedule,""
"DIDANOSINE 200 MG PO CPDR",0250,A9270,00555058801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,26.08 ,18.26 ,Aetna,"AETNA",11.74,45,percent of total billed charges,999999999,0.03087,18.256,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIDANOSINE 250 MG PO CPDR",0250,A9270,00555058901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,32.94 ,23.06 ,Aetna,"AETNA",14.82,45,percent of total billed charges,999999999,0.03087,23.058,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIDANOSINE 400 MG PO CPDR",0250,A9270,00555059001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IRON SUCROSE 20 MG/ML IV SOLN",0250,J1756,00517234010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,367.14 ,257.00 ,Aetna,"AETNA",0.44,191,fee schedule,999999999,0.2,256.998,fee schedule,""
"GABAPENTIN 250 MG/5ML PO SOLN",0250,A9270,42192060816,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24",0250,A9270,60687019501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24",0250,A9270,60687019511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24",0250,A9270,60687020601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24",0250,A9270,60687020611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24",0250,A9270,00904721961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24",0250,A9270,24979002907,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL ER BEADS 360 MG PO CP24",0250,A9270,47335067381,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.12 ,3.58 ,Aetna,"AETNA",2.30,45,percent of total billed charges,999999999,0.03087,3.584,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN",0250,J7510,00121075908,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.55,191,fee schedule,999999999,0.23,4.76,fee schedule,""
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN",0250,J7510,99999747299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,6.80 ,4.76 ,Aetna,"AETNA",0.55,191,fee schedule,999999999,0.23,4.76,fee schedule,""
"ESTRADIOL VALERATE 40 MG/ML IM OIL",0250,J1380,00574087205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,59.84 ,41.89 ,Aetna,"AETNA",16.54,191,fee schedule,999999999,9.236,41.888,fee schedule,""
"PROPRANOLOL HCL 1 MG/ML IV SOLN",0250,J1800,00143987201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,69.99 ,48.99 ,Aetna,"AETNA",20.70,191,fee schedule,999999999,3.834,48.993,fee schedule,""
"PROPRANOLOL HCL 1 MG/ML IV SOLN",0250,J1800,00143987210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12.78 ,8.95 ,Aetna,"AETNA",20.70,191,fee schedule,999999999,3.834,48.993,fee schedule,""
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR",0250,J0583,00781315894,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1040.51 ,728.36 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.19,728.357,fee schedule,""
"BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR",0250,J0583,00781315895,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,208.04 ,145.63 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.19,728.357,fee schedule,""
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA",0250,A9270,00168025815,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,30.98 ,21.69 ,Aetna,"AETNA",13.94,45,percent of total billed charges,999999999,0.03087,21.686,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NATEGLINIDE 60 MG PO TABS",0250,A9270,00078035105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,23.63 ,16.54 ,Aetna,"AETNA",10.63,45,percent of total billed charges,999999999,0.03087,16.541,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NATEGLINIDE 120 MG PO TABS",0250,A9270,68084045921,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.74 ,4.02 ,Aetna,"AETNA",2.58,45,percent of total billed charges,999999999,0.03087,4.018,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NATEGLINIDE 120 MG PO TABS",0250,A9270,68084045911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.64 ,3.95 ,Aetna,"AETNA",2.54,45,percent of total billed charges,999999999,0.03087,4.018,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TACROLIMUS 0.1 % EX OINT",0250,A9270,45802070000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,257.40 ,180.18 ,Aetna,"AETNA",115.83,45,percent of total billed charges,999999999,0.03087,180.18,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN",0250,J2274,00409381412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,50.75 ,35.53 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,99.876,fee schedule,""
"MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN",0250,J2274,00641602010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,142.68 ,99.88 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,99.876,fee schedule,""
"MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN",0250,J2274,99999020999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,58.00 ,40.60 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,99.876,fee schedule,""
"MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN",0250,J2274,00409381411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,50.75 ,35.53 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,11.19,99.876,fee schedule,""
"MIRTAZAPINE 15 MG PO TBDP",0250,A9270,65862002106,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 30 MG PO TBDP",0250,A9270,66993071130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 30 MG PO TBDP",0250,A9270,65862002206,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CASPOFUNGIN ACETATE 50 MG IV SOLR",0250,J0637,00006382210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1572.20 ,1100.54 ,Aetna,"AETNA",12.66,191,fee schedule,999999999,5.427,1100.54,fee schedule,""
"CASPOFUNGIN ACETATE 70 MG IV SOLR",0250,J0637,00006382310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1633.50 ,1143.45 ,Aetna,"AETNA",12.66,191,fee schedule,999999999,5.427,1143.45,fee schedule,""
"PEGINTERFERON ALFA-2B 50 MCG/0.5ML SC KIT",0250,,00085136801,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,2840.60 ,1988.42 ,Aetna,"AETNA",1278.27,45,percent of total billed charges,999999999,852.18,1988.42,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIPRASIDONE HCL 20 MG PO CAPS",0250,A9270,55111025660,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIPRASIDONE HCL 40 MG PO CAPS",0250,A9270,00904627008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIPRASIDONE HCL 60 MG PO CAPS",0250,A9270,55111025860,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZIPRASIDONE HCL 80 MG PO CAPS",0250,A9270,00904627208,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.46 ,9.42 ,Aetna,"AETNA",6.06,45,percent of total billed charges,999999999,0.03087,9.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYPROMELLOSE 2 % IO SOLN",0250,,57770005500,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,63,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL SUCCINATE ER 25 MG PO TB24",0250,A9270,00904632206,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EYE STREAM OP SOLN",0250,A9270,00065053004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ML,,192.58 ,134.81 ,Aetna,"AETNA",86.66,45,percent of total billed charges,999999999,0.03087,134.806,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE 10 MCG/ML IN 10 ML SYRINGE",0250,J0171,70092161746,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.08 ,3.56 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,3.556,fee schedule,""
"LIDOCAINE-EPINEPHRINE 1%/1MG/ML SYRINGE OR",0250,,99999024099,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,5.01 ,3.51 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.503,3.507,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 1 MG PO TABS (PEDS)",0250,A9270,00054817425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE HCL 1 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J0171,42023015925,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,630,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J0171,42023016801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,900.00 ,630.00 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,630,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J0171,42023015901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,78.74 ,55.12 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,630,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J0171,00517117101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,55.92 ,39.14 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,630,fee schedule,""
"EPINEPHRINE HCL 1 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J0171,00517117110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,55.92 ,39.14 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,630,fee schedule,""
"DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J1200,63323066401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.89 ,4.12 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.804,4.123,fee schedule,""
"HYDROCORTISONE NA SUCCINATE PF 100 MG INJ SOLR FOR HYPERSENSITIVY (PEDS)",0250,J1720,00009001103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,112.56 ,78.79 ,Aetna,"AETNA",35.26,191,fee schedule,999999999,17.51,78.792,fee schedule,""
"FAMOTIDINE 10 MG/ML IV SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J3490,63323073911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.07 ,3.55 ,Aetna,"AETNA",2.28,45,percent of total billed charges,999999999,0,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J3490,63323073806,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,0,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J3490,63323073820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,0,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAMOTIDINE 10 MG/ML IV SOLN FOR HYPERSENSITIVITY (PEDS)",0250,J3490,63323073912,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.07 ,3.55 ,Aetna,"AETNA",2.28,45,percent of total billed charges,999999999,0,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPARIN LOCK FLUSH 1 UNIT/ML IV IN NA ACETATE",0250,J1642,99990035299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,44.52 ,31.16 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,31.164,fee schedule,""
"METOPROLOL SUCCINATE ER 50 MG PO TB24",0250,A9270,00904632361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL SUCCINATE ER 100 MG PO TB24",0250,A9270,50268054211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL SUCCINATE ER 100 MG PO TB24",0250,A9270,50268054215,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALGANCICLOVIR HCL 450 MG PO TABS",0250,A9270,00004003822,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,491.00 ,343.70 ,Aetna,"AETNA",220.95,45,percent of total billed charges,999999999,0.03087,343.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CITALOPRAM HYDROBROMIDE 10 MG PO TABS",0250,A9270,00904608461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909431,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909332,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909422,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909441,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909418,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909337,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"FENTANYL CITRATE (PF) 0.05 MG/ML INJ SOLN (WRAPPED)",0250,J3010,00409909416,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"OXCARBAZEPINE 300 MG/5ML PO SUSP",0250,A9270,65162064978,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,14.16 ,9.91 ,Aetna,"AETNA",6.37,45,percent of total billed charges,999999999,0.03087,9.912,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML INH SOLN",0250,,69097017353,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS GLUCONATE 324 (38 FE) MG PO TABS",0250,A9270,00574050801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIPOIC ACID POWD",0250,,49452408302,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,37.03 ,25.92 ,Aetna,"AETNA",16.66,45,percent of total billed charges,999999999,11.109,25.921,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS SULFATE 325 (65 FE) MG PO TABS",0250,A9270,00904759182,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FIBERSOURCE HN PO LIQD",0250,,43900018555,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,8.75 ,6.13 ,Aetna,"AETNA",3.94,45,percent of total billed charges,999999999,2.625,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FIBERSOURCE HN PO LIQD",0250,,43900018588,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,2.625,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALLOPURINOL 100 MG PO TABS",0250,A9270,00904704161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PACLITAXEL 100 MG/16.7ML IV CONC",0250,J9267,67457044917,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,90.58 ,63.41 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.108,63.406,fee schedule,""
"PACLITAXEL 300 MG/50ML IV CONC",0250,J9267,70860020050,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,279.30 ,195.51 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.108,195.51,fee schedule,""
"ALLOPURINOL 300 MG PO TABS",0250,A9270,00904657261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FISH OIL 1000 MG PO CAPS",0250,A9270,77333030810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR",0250,A9270,65862053575,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,58.28 ,40.80 ,Aetna,"AETNA",26.23,45,percent of total billed charges,999999999,0.03087,40.796,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VALSARTAN 80 MG PO TABS",0250,A9270,43547036809,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLEET ENEMA 7-19 GM/118ML PR ENEM",0250,,00536741551,RC,,NDC,FACILITY,OUTPATIENT,133,ML,,11.17 ,7.82 ,Aetna,"AETNA",5.03,45,percent of total billed charges,999999999,3.351,7.819,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLEET PEDIATRIC 3.5-9.5 GM/59ML PR ENEM",0250,A9270,00132020220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,11.09 ,7.76 ,Aetna,"AETNA",4.99,45,percent of total billed charges,999999999,0.03087,7.763,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALTEPLASE 2 MG INJ SOLR",0250,J2997,50242004164,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,900.00 ,630.00 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,630,fee schedule,""
"DIGOXIN IMMUNE FAB 40 MG IV SOLR",0250,J1162,50633012011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,64231.95 ,44962.37 ,Aetna,"AETNA",9124.91,191,fee schedule,999999999,4294.08,44962.365,fee schedule,""
"AMPHETAMINE-DEXTROAMPHET ER 10 MG PO CP24",0250,A9270,54092038301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,46.42 ,32.49 ,Aetna,"AETNA",20.89,45,percent of total billed charges,999999999,0.03087,32.494,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS",0250,A9270,33342009607,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PARICALCITOL 2 MCG/ML IV SOLN",0250,J2501,00074463701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,26.07 ,18.25 ,Aetna,"AETNA",1.43,191,fee schedule,999999999,0.5,18.249,fee schedule,""
"BOOST BREEZE PO LIQD",0250,,43900018629,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,9.95 ,6.97 ,Aetna,"AETNA",4.48,45,percent of total billed charges,999999999,2.49,6.965,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST BREEZE PO LIQD",0250,,43900018666,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,8.30 ,5.81 ,Aetna,"AETNA",3.74,45,percent of total billed charges,999999999,2.49,6.965,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS",0250,A9270,00406052262,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,11.06 ,7.74 ,Aetna,"AETNA",4.98,45,percent of total billed charges,999999999,0.03087,7.742,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS",0250,A9270,00406052223,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,7.742,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS",0250,A9270,00904709561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.94 ,5.56 ,Aetna,"AETNA",3.57,45,percent of total billed charges,999999999,0.03087,5.558,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOCINONIDE 0.05 % EX CREA",0250,A9270,51672138602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,108.54 ,75.98 ,Aetna,"AETNA",48.84,45,percent of total billed charges,999999999,0.03087,75.978,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ERTAPENEM SODIUM 1 G INJ SOLR",0250,J1335,44567082001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,93.69 ,65.58 ,Aetna,"AETNA",22.73,191,fee schedule,999999999,12.91,65.583,fee schedule,""
"ERTAPENEM SODIUM 1 G INJ SOLR",0250,J1335,44567082010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,93.69 ,65.58 ,Aetna,"AETNA",22.73,191,fee schedule,999999999,12.91,65.583,fee schedule,""
"FLUOROMETHOLONE 0.1 % OP SUSP",0250,A9270,60219158503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,459.66 ,321.76 ,Aetna,"AETNA",206.85,45,percent of total billed charges,999999999,0.03087,321.762,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN",0250,J2680,63323027205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,28.06 ,19.64 ,Aetna,"AETNA",18.57,191,fee schedule,999999999,8.418,19.642,fee schedule,""
"FLUPHENAZINE HCL 2.5 MG/ML INJ SOLN",0250,J2679,63323028110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,ME,,532.92 ,373.04 ,Aetna,"AETNA",15.07,191,fee schedule,999999999,7.545,373.044,fee schedule,""
"FLUPHENAZINE HCL 1 MG PO TABS",0250,A9270,70954027310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN",0250,J1652,67457058210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,65.30 ,45.71 ,Aetna,"AETNA",1.97,191,fee schedule,999999999,1.02,45.71,fee schedule,""
"FOLIC ACID 5 MG/ML INJ SOLN",0250,,63323018410,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,128.70 ,90.09 ,Aetna,"AETNA",57.92,45,percent of total billed charges,999999999,38.61,90.09,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FOLIC ACID 1 MG PO TABS",0250,A9270,60687068101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALPRAZOLAM 0.25 MG PO TABS",0250,A9270,65862067601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALPRAZOLAM 0.5 MG PO TABS",0250,A9270,65862067701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TALC 4 G PL AERP",0250,,63256010030,RC,,NDC,FACILITY,OUTPATIENT,4,GR,,80.00 ,56.00 ,Aetna,"AETNA",36.00,45,percent of total billed charges,999999999,24,56,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN",0250,J2430,67457043010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,60.62 ,42.43 ,Aetna,"AETNA",26.93,191,fee schedule,999999999,8.874,42.434,fee schedule,""
"ALPRAZOLAM 1 MG PO TABS",0250,A9270,65862067801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLMESARTAN MEDOXOMIL 20 MG PO TABS",0250,A9270,68462043790,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAMIDRONATE DISODIUM 90 MG/10ML IV SOLN",0250,J2430,67457044610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,165.90 ,116.13 ,Aetna,"AETNA",26.93,191,fee schedule,999999999,8.874,116.13,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050143,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050164,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML INJ SOLN",0250,J1940,16729050243,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"FUROSEMIDE 10 MG/ML PO SOLN",0250,A9270,00054329450,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FUROSEMIDE 20 MG PO TABS",0250,A9270,00904717761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FUROSEMIDE 40 MG PO TABS",0250,A9270,00904717861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FUROSEMIDE 80 MG PO TABS",0250,A9270,43547040310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IMATINIB MESYLATE 100 MG PO TABS",0250,A9270,72485020290,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 50 MG PO TABS",0250,A9270,27241006203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.65 ,6.06 ,Aetna,"AETNA",3.89,45,percent of total billed charges,999999999,0.03087,6.055,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 200 MG PO TABS",0250,A9270,27241006303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 200 MG IV SOLR",0250,J3465,72266013101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,85.98 ,60.19 ,Aetna,"AETNA",2.10,191,fee schedule,999999999,0.68,60.186,fee schedule,""
"ZIPRASIDONE MESYLATE 20 MG IM SOLR",0250,J3486,43598084858,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,41.23 ,28.86 ,Aetna,"AETNA",19.52,191,fee schedule,999999999,9.6,28.861,fee schedule,""
"ZIPRASIDONE MESYLATE 20 MG IM SOLR",0250,J3486,43598084811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,41.23 ,28.86 ,Aetna,"AETNA",19.52,191,fee schedule,999999999,9.6,28.861,fee schedule,""
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS",0250,A9270,66685100202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.78 ,6.85 ,Aetna,"AETNA",4.40,45,percent of total billed charges,999999999,0.03087,10.185,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS",0250,A9270,66685100200,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.55 ,10.19 ,Aetna,"AETNA",6.55,45,percent of total billed charges,999999999,0.03087,10.185,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS",0250,A9270,00093227434,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,10.185,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS",0250,A9270,00093227534,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 200-28.5 MG/5ML PO SUSR",0250,A9270,65862053350,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,33.25 ,23.28 ,Aetna,"AETNA",14.96,45,percent of total billed charges,999999999,0.03087,23.275,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR",0250,A9270,65862053450,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,27.30 ,19.11 ,Aetna,"AETNA",12.29,45,percent of total billed charges,999999999,0.03087,19.11,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRENATAL PLUS 27-1 MG PO TABS",0250,A9270,39328010610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESCITALOPRAM OXALATE 10 MG PO TABS",0250,A9270,00904642661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RASBURICASE 1.5 MG IV SOLR",0250,J2783,00024515010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,3211.30 ,2247.91 ,Aetna,"AETNA",701.89,191,fee schedule,999999999,332.08,2247.91,fee schedule,""
"GEMFIBROZIL 600 MG PO TABS",0250,A9270,60687022401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GEMFIBROZIL 600 MG PO TABS",0250,A9270,60687022411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METAXALONE 800 MG PO TABS",0250,A9270,55111065001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EZETIMIBE 10 MG PO TABS",0250,A9270,67877049090,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTAMICIN SULFATE 0.1 % EX CREA",0250,A9270,00713068315,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,62.48 ,43.74 ,Aetna,"AETNA",28.12,45,percent of total billed charges,999999999,0.03087,43.736,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTAMICIN SULFATE 10 MG/ML INJ SOLN",0250,J1580,63323017302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,13.43 ,9.40 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.66,9.401,fee schedule,""
"GENTAMICIN SULFATE 40 MG/ML INJ SOLN",0250,J1580,63323001003,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,138.00 ,96.60 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.4,96.6,fee schedule,""
"GENTAMICIN SULFATE 40 MG/ML INJ SOLN",0250,J1580,63323001001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,8.00 ,5.60 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.4,96.6,fee schedule,""
"GENTAMICIN SULFATE 40 MG/ML INJ SOLN",0250,J1580,63323001002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,8.00 ,5.60 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.4,96.6,fee schedule,""
"GENTAMICIN SULFATE 40 MG/ML INJ SOLN",0250,J1580,63323001020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,138.00 ,96.60 ,Aetna,"AETNA",5.21,191,fee schedule,999999999,2.4,96.6,fee schedule,""
"GENTAMICIN SULFATE 0.3 % OP OINT",0250,,48102000935,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,279.91 ,195.94 ,Aetna,"AETNA",125.96,45,percent of total billed charges,999999999,57.261,195.937,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTAMICIN SULFATE 0.3 % OP OINT",0250,,17478028435,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,190.87 ,133.61 ,Aetna,"AETNA",85.89,45,percent of total billed charges,999999999,57.261,195.937,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTAMICIN SULFATE 0.3 % OP SOLN",0250,,61314063305,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,33.46 ,23.42 ,Aetna,"AETNA",15.06,45,percent of total billed charges,999999999,10.038,23.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTIAN VIOLET 1 % EX SOLN",0250,A9270,00395100392,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,25.41 ,17.79 ,Aetna,"AETNA",11.43,45,percent of total billed charges,999999999,0.03087,17.787,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARIPIPRAZOLE 10 MG PO TABS",0250,A9270,50268008915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARIPIPRAZOLE 10 MG PO TABS",0250,A9270,50268008911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARIPIPRAZOLE 15 MG PO TABS",0250,A9270,65162089903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIVALPROEX SODIUM ER 250 MG PO TB24",0250,A9270,65162075510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS",0250,A9270,60687039601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE HCL 2 MG SL SUBL",0250,A9270,00054017613,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE HCL 8 MG SL SUBL",0250,A9270,00054017713,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.76 ,6.13 ,Aetna,"AETNA",3.94,45,percent of total billed charges,999999999,0.03087,6.132,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL",0250,J0572,50268014411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.61 ,10.23 ,Aetna,"AETNA",8.98,191,fee schedule,999999999,3.65,10.227,fee schedule,""
"BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL",0250,J0572,50268014415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.60 ,10.22 ,Aetna,"AETNA",8.98,191,fee schedule,999999999,3.65,10.227,fee schedule,""
"BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL",0250,J0574,00054018913,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.45 ,7.32 ,Aetna,"AETNA",17.78,191,fee schedule,999999999,2.6125,17.7821,fee schedule,""
"NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN",0250,A9270,24208063110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,274.62 ,192.23 ,Aetna,"AETNA",123.58,45,percent of total billed charges,999999999,0.03087,192.234,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYBURIDE 5 MG PO TABS",0250,A9270,23155005801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYCOPYRROLATE 0.2 MG/ML INJ SOLN",0250,J1596,71288041401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,3.5,fee schedule,""
"GLYCOPYRROLATE 0.2 MG/ML INJ SOLN",0250,J1596,71288041403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,3.5,fee schedule,""
"NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OP SUSP",0250,A9270,61314064175,RC,HCPCS,NDC,FACILITY,OUTPATIENT,7.5,ML,,805.50 ,563.85 ,Aetna,"AETNA",362.48,45,percent of total billed charges,999999999,0.03087,563.85,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROSUVASTATIN CALCIUM 10 MG PO TABS",0250,A9270,50268070911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROSUVASTATIN CALCIUM 10 MG PO TABS",0250,A9270,50268070915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROSUVASTATIN CALCIUM 20 MG PO TABS",0250,A9270,68462026390,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOBENZAPRINE HCL 5 MG PO TABS",0250,A9270,68084075325,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOBENZAPRINE HCL 5 MG PO TABS",0250,A9270,68084075395,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN",0250,J1805,67457065810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,352.20 ,246.54 ,Aetna,"AETNA",0.42,191,fee schedule,999999999,0.24,246.54,fee schedule,""
"ZOLEDRONIC ACID 4 MG/5ML IV CONC",0250,J3489,55111068507,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,50.61 ,35.43 ,Aetna,"AETNA",13.26,191,fee schedule,999999999,6.93,35.427,fee schedule,""
"MOXIFLOXACIN HCL 0.5 % OP SOLN",0250,,68180042201,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,67.56 ,47.29 ,Aetna,"AETNA",30.40,45,percent of total billed charges,999999999,20.268,47.292,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METFORMIN HCL ER 750 MG PO TB24",0250,A9270,50268055115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AGALSIDASE BETA 35 MG IV SOLR",0250,J0180,58468004001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,21712.80 ,15198.96 ,Aetna,"AETNA",416.91,191,fee schedule,999999999,207.86,15198.96,fee schedule,""
"LARONIDASE 2.9 MG/5ML IV SOLN",0250,J1931,58468007001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,3088.14 ,2161.70 ,Aetna,"AETNA",71.51,191,fee schedule,999999999,36.11,2161.698,fee schedule,""
"HALOPERIDOL 0.5 MG PO TABS",0250,A9270,00378035101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HALOPERIDOL 1 MG PO TABS",0250,A9270,00904739061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIABETISOURCE AC PO LIQD",0250,,43900036500,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIABETISOURCE AC PO LIQD",0250,,43900036508,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,6.3,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HALOPERIDOL 2 MG PO TABS",0250,A9270,51079073520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.50 ,3.85 ,Aetna,"AETNA",2.48,45,percent of total billed charges,999999999,0.03087,3.85,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HALOPERIDOL 2 MG PO TABS",0250,A9270,51079073501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.85,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HALOPERIDOL 5 MG PO TABS",0250,A9270,00904678261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HALOPERIDOL LACTATE 5 MG/ML INJ SOLN",0250,J1630,25021080601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.41,191,fee schedule,999999999,1.24,3.5,fee schedule,""
"HALOPERIDOL LACTATE 5 MG/ML INJ SOLN",0250,J1630,76045073701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.41,191,fee schedule,999999999,1.24,3.5,fee schedule,""
"HALOPERIDOL LACTATE 5 MG/ML INJ SOLN",0250,J1630,76045073710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.41,191,fee schedule,999999999,1.24,3.5,fee schedule,""
"HALOPERIDOL LACTATE 2 MG/ML PO CONC",0250,A9270,54838050140,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR",0250,A9270,00245531901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE SOD PHOSPHATE 4 MG/ML INJ",0250,J1100,67457042254,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,""
"DEXAMETHASONE SOD PHOSPHATE 4 MG/ML INJ",0250,J1100,00641614501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,""
"DEXAMETHASONE SOD PHOSPHATE 4 MG/ML INJ",0250,J1100,00641614525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,""
"DEXAMETHASONE SOD PHOSPHATE 4 MG/ML INJ",0250,J1100,63323016530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,""
"POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN",0250,J3480,00338070434,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,21.00 ,14.70 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,14.7,fee schedule,""
"IMATINIB MESYLATE 400 MG PO TABS",0250,A9270,00093763056,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,47.01 ,32.91 ,Aetna,"AETNA",21.15,45,percent of total billed charges,999999999,0.03087,32.907,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATAZANAVIR SULFATE 150 MG PO CAPS",0250,A9270,69097044403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,42.55 ,29.79 ,Aetna,"AETNA",19.15,45,percent of total billed charges,999999999,0.03087,29.785,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMALIZUMAB 150 MG SC SOLR",0250,J2357,50242004062,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,4139.10 ,2897.37 ,Aetna,"AETNA",70.31,191,fee schedule,999999999,38.65,2897.37,fee schedule,""
"ESTROGENS CONJUGATED 0.45 MG PO TABS",0250,A9270,00046110181,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,45.01 ,31.51 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,0.03087,31.507,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARIPIPRAZOLE 5 MG PO TABS",0250,A9270,65162089709,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP",0250,,43598032675,RC,,NDC,FACILITY,OUTPATIENT,7.5,ML,,705.74 ,494.02 ,Aetna,"AETNA",317.58,45,percent of total billed charges,999999999,211.722,494.018,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVETIRACETAM 100 MG/ML PO SOLN",0250,A9270,65862025047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PALONOSETRON HCL 0.25 MG/5ML IV SOLN",0250,J2469,00703409401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,mcg,,28.84 ,20.19 ,Aetna,"AETNA",2.27,191,fee schedule,999999999,0.845,20.188,fee schedule,""
"ROSUVASTATIN CALCIUM 5 MG PO TABS",0250,A9270,68462026190,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HOMATROPINE HBR 5 % OP SOLN",0250,,59390019205,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,111.90 ,78.33 ,Aetna,"AETNA",50.36,45,percent of total billed charges,999999999,33.57,78.33,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIODARONE HCL 100 MG PO TABS",0250,A9270,00245014489,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,27.43 ,19.20 ,Aetna,"AETNA",12.34,45,percent of total billed charges,999999999,0.03087,19.201,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIODARONE HCL 100 MG PO TABS",0250,A9270,00245014401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,19.201,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEMANTINE HCL 10 MG PO TABS",0250,A9270,00591387544,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEMANTINE HCL 10 MG PO TABS",0250,A9270,00591387545,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDRALAZINE HCL 20 MG/ML INJ SOLN",0250,J0360,00641623101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,6.39 ,4.47 ,Aetna,"AETNA",10.62,191,fee schedule,999999999,1.917,10.6196,fee schedule,""
"HYDRALAZINE HCL 20 MG/ML INJ SOLN",0250,J0360,00641623125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,6.39 ,4.47 ,Aetna,"AETNA",10.62,191,fee schedule,999999999,1.917,10.6196,fee schedule,""
"THEOPHYLLINE ER 400 MG PO TB24",0250,A9270,68462038001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOL 1.4 % MT LIQD",0250,A9270,00904630521,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,16.11 ,11.28 ,Aetna,"AETNA",7.25,45,percent of total billed charges,999999999,0.03087,11.277,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDRALAZINE HCL 10 MG PO TABS",0250,A9270,51079007420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPLERENONE 25 MG PO TABS",0250,A9270,66993034330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.79 ,9.65 ,Aetna,"AETNA",6.21,45,percent of total billed charges,999999999,0.03087,9.653,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TADALAFIL 20 MG PO TABS",0250,A9270,29300028913,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZONISAMIDE 50 MG PO CAPS",0250,A9270,72578004101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAPTOMYCIN 500 MG IV SOLR",0250,J0878,71288001615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,86.70 ,60.69 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.038,60.69,fee schedule,""
"HYDRALAZINE HCL 25 MG PO TABS",0250,A9270,63739032710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDRALAZINE HCL 50 MG PO TABS",0250,A9270,63739032810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEMANTINE HCL 5 MG PO TABS",0250,A9270,00591387044,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCHLOROTHIAZIDE 25 MG PO TABS",0250,A9270,16729018301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCHLOROTHIAZIDE 50 MG PO TABS",0250,A9270,23155000901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM FLUORIDE 1.1 (0.5 F) MG/ML PO SOLN",0250,A9270,44946103208,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,44.10 ,30.87 ,Aetna,"AETNA",19.85,45,percent of total billed charges,999999999,0.03087,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 0.5 % EX CREA",0250,A9270,51672201002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,33.60 ,23.52 ,Aetna,"AETNA",15.12,45,percent of total billed charges,999999999,0.03087,23.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 1 % EX CREA",0250,A9270,00536127780,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 2.5 % EX CREA",0250,A9270,51672300302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,19.25 ,13.48 ,Aetna,"AETNA",8.66,45,percent of total billed charges,999999999,0.03087,13.475,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 2.5 % EX CREA",0250,A9270,00168008031,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,14.70 ,10.29 ,Aetna,"AETNA",6.62,45,percent of total billed charges,999999999,0.03087,13.475,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 1 % EX LOTN",0250,,00096073204,RC,,NDC,FACILITY,OUTPATIENT,120,ML,,95.76 ,67.03 ,Aetna,"AETNA",43.09,45,percent of total billed charges,999999999,28.728,67.032,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 1 % EX OINT",0250,A9270,45802027603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,13.72 ,9.60 ,Aetna,"AETNA",6.17,45,percent of total billed charges,999999999,0.03087,9.604,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 2.5 % EX OINT",0250,A9270,00168014630,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,23.22 ,16.25 ,Aetna,"AETNA",10.45,45,percent of total billed charges,999999999,0.03087,16.254,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 10 MG PO TABS",0250,A9270,59762007401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE 20 MG PO TABS",0250,A9270,00115170001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROMETHORPHAN HBR 15 MG PO CAPS",0250,A9270,00536132334,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE ACETATE 25 MG PR SUPP",0250,A9270,16571067621,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.54 ,3.88 ,Aetna,"AETNA",2.49,45,percent of total billed charges,999999999,0.03087,3.878,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHOLESTYRAMINE LIGHT 4 G PO PACK",0250,A9270,68382052960,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BSS IO SOLN",0250,,00065079515,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,36.23 ,25.36 ,Aetna,"AETNA",16.30,45,percent of total billed charges,999999999,10.869,25.361,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROMORPHONE HCL 2 MG/ML INJ SOLN",0250,J1170,00641234139,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,5.00 ,3.50 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,1.5,10.731,fee schedule,""
"HYDROMORPHONE HCL 2 MG/ML INJ SOLN",0250,J1170,00641234141,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,5.92 ,4.14 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,1.5,10.731,fee schedule,""
"HYDROMORPHONE HCL 2 MG/ML INJ SOLN",0250,J1170,00641615101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,9.98 ,6.99 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,1.5,10.731,fee schedule,""
"HYDROMORPHONE HCL 2 MG/ML INJ SOLN",0250,J1170,00641615125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,15.33 ,10.73 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,1.5,10.731,fee schedule,""
"HYDROMORPHONE HCL 2 MG PO TABS",0250,A9270,42858030125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROMORPHONE HCL 4 MG PO TABS",0250,A9270,42858030225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESCITALOPRAM OXALATE 5 MG PO TABS",0250,A9270,43547028010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL TARTRATE 25 MG PO TABS",0250,A9270,51079025520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL TARTRATE 25 MG PO TABS",0250,A9270,00904634061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR",0250,A9270,23155060351,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,7.53 ,5.27 ,Aetna,"AETNA",3.39,45,percent of total billed charges,999999999,0.03087,5.271,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIPIZIDE ER 2.5 MG PO TB24",0250,A9270,68084029511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.60 ,4.62 ,Aetna,"AETNA",2.97,45,percent of total billed charges,999999999,0.03087,5.544,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIPIZIDE ER 2.5 MG PO TB24",0250,A9270,68084029521,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.92 ,5.54 ,Aetna,"AETNA",3.56,45,percent of total billed charges,999999999,0.03087,5.544,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIPIZIDE ER 5 MG PO TB24",0250,A9270,68084011101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLIPIZIDE ER 5 MG PO TB24",0250,A9270,68084011111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUAIFENESIN ER 600 MG PO TB12",0250,A9270,00904698640,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYZINE HCL 25 MG/ML IM SOLN",0250,J3410,00517420125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,87.32 ,61.12 ,Aetna,"AETNA",26.49,191,fee schedule,999999999,9.908,61.124,fee schedule,""
"HYDROXYZINE HCL 10 MG/5ML PO SYRP",0250,A9270,54838050280,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYZINE HCL 10 MG/5ML PO SYRP",0250,A9270,99999025199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYZINE HCL 10 MG PO TABS",0250,A9270,63739048310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYZINE HCL 25 MG PO TABS",0250,A9270,23155010601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYZINE HCL 50 MG PO TABS",0250,A9270,00904661861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX",0250,A9270,99999071099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX",0250,A9270,54838051180,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYOSCYAMINE SULFATE 0.125 MG/ML PO SOLN",0250,A9270,54838050615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN",0250,A9270,00121231650,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,35.70 ,24.99 ,Aetna,"AETNA",16.07,45,percent of total billed charges,999999999,0.03087,24.99,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN",0250,A9270,64950034316,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,25.15 ,17.61 ,Aetna,"AETNA",11.32,45,percent of total billed charges,999999999,0.03087,24.99,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEMETREXED DISODIUM 500 MG IV SOLR",0250,J9305,00002762301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11825.79 ,8278.05 ,Aetna,"AETNA",7.58,191,fee schedule,999999999,3.22,8278.053,fee schedule,""
"CETUXIMAB 100 MG/50ML IV SOLN",0250,J9055,66733094823,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",140.37,191,fee schedule,999999999,69.09,2100,fee schedule,""
"PROPOFOL 20 ML VIAL (RWN)",0250,J2704,63323026929,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.42 ,10.09 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.1,10.094,fee schedule,""
"PROPOFOL 20 ML VIAL (RWN)",0250,J2704,63323026922,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.42 ,10.09 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.1,10.094,fee schedule,""
"MYCOPHENOLATE SODIUM 360 MG PO TBEC",0250,,00078038666,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,75.82 ,53.07 ,Aetna,"AETNA",34.12,45,percent of total billed charges,999999999,22.746,53.074,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CINACALCET HCL 30 MG PO TABS",0250,A9270,64380088304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,0.03087,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 40 MG/ML PO SUSR",0250,A9270,999997364A99,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,112.20 ,78.54 ,Aetna,"AETNA",50.49,45,percent of total billed charges,999999999,0.03087,78.54,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 40 MG/ML PO SUSR",0250,A9270,99999060499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.97 ,4.18 ,Aetna,"AETNA",2.69,45,percent of total billed charges,999999999,0.03087,78.54,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL ER 60 MG PO CP24",0250,A9270,00527411637,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL ER 80 MG PO CP24",0250,A9270,00527411737,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE 10 GM/15ML PO SOLN",0250,A9270,00121115430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,79.20 ,55.44 ,Aetna,"AETNA",35.64,45,percent of total billed charges,999999999,0.03087,76.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE 10 GM/15ML PO SOLN",0250,A9270,00121115440,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,109.20 ,76.44 ,Aetna,"AETNA",49.14,45,percent of total billed charges,999999999,0.03087,76.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE 10 GM/15ML PO SOLN",0250,A9270,60432003732,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,37.80 ,26.46 ,Aetna,"AETNA",17.01,45,percent of total billed charges,999999999,0.03087,76.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPHOSPHAMIDE 1 G INJ SOLR",0250,J9075,10019095601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1372.65 ,960.86 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,960.855,fee schedule,""
"CYCLOPHOSPHAMIDE 1 G INJ SOLR",0250,J9075,00781324494,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,931.10 ,651.77 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,960.855,fee schedule,""
"CYCLOPHOSPHAMIDE 1 G INJ SOLR",0250,J9075,70121123901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,900.00 ,630.00 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,960.855,fee schedule,""
"CYCLOPHOSPHAMIDE 500 MG INJ SOLR",0250,J9075,10019095501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,823.56 ,576.49 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,576.492,fee schedule,""
"CYCLOPHOSPHAMIDE 500 MG INJ SOLR",0250,J9075,00781323394,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,502.80 ,351.96 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,576.492,fee schedule,""
"CYCLOPHOSPHAMIDE 500 MG INJ SOLR",0250,J9075,70121123801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,560.52 ,392.36 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,576.492,fee schedule,""
"CYCLOPHOSPHAMIDE 2 G INJ SOLR",0250,J9075,10019095701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,1,1750,fee schedule,""
"ACETYLCYSTEINE 200 MG/ML IV SOLN",0250,J0132,25021081230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,331.02 ,231.71 ,Aetna,"AETNA",1.47,191,fee schedule,999999999,0.65,231.714,fee schedule,""
"IBUPROFEN 200 MG PO TABS",0250,A9270,00904791461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRTAZAPINE 7.5 MG PO TABS",0250,A9270,13107000130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 400 MG PO TABS",0250,A9270,67877031901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 600 MG PO TABS",0250,A9270,00904585461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUPROFEN 800 MG PO TABS",0250,A9270,00904585561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOXETINE HCL 20 MG/5ML PO SOLN",0250,A9270,70954060010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AGALSIDASE BETA 5 MG IV SOLR",0250,J0180,58468004101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3101.31 ,2170.92 ,Aetna,"AETNA",416.91,191,fee schedule,999999999,207.86,2170.917,fee schedule,""
"IMIPRAMINE HCL 10 MG PO TABS",0250,A9270,64380016901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IMIPRAMINE HCL 25 MG PO TABS",0250,A9270,64380017001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT",0250,,24208078055,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,405.30 ,283.71 ,Aetna,"AETNA",182.39,45,percent of total billed charges,999999999,121.59,283.71,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ADENOSINE 6 MG/2ML IV SOLN",0250,J0153,67457085502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.29 ,3.70 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,3.703,fee schedule,""
"ADENOSINE 6 MG/2ML IV SOLN",0250,J0153,67457085500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.29 ,3.70 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,3.703,fee schedule,""
"INDAPAMIDE 2.5 MG PO TABS",0250,A9270,62559051101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTULOSE ENCEPHALOPATHY 10 GM/15ML PO SOLN",0250,A9270,45963043864,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN 25 MG PO CAPS",0250,A9270,51079019020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN 50 MG PO CAPS",0250,A9270,50268043111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN 50 MG PO CAPS",0250,A9270,50268043115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTAZIDIME (PEDS) INJ PER 250 MG",0250,J0713,99999348699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.67 ,8.87 ,Aetna,"AETNA",3.17,191,fee schedule,999999999,1.694,8.869,fee schedule,""
"CLINDAMYCIN (PEDS) INJ PER 100 MG",0250,,99999347599,RC,,NDC,FACILITY,OUTPATIENT,100,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 2 ML (PEDS)",0250,,00703951401,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN (PEDS) INJ PER 100 MG",0250,J3370,99999347499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,1.5,4.9278,fee schedule,""
"SUCROSE 24%",0250,A9270,08283000696,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,6.468,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCROSE 24%",0250,A9270,89805063745,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.24 ,6.47 ,Aetna,"AETNA",4.16,45,percent of total billed charges,999999999,0.03087,6.468,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAFFEINE CITRATE NICU INJ",0250,J0706,99999694699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,16.91 ,11.84 ,Aetna,"AETNA",3.92,191,fee schedule,999999999,1.71,11.837,fee schedule,""
"HEPARIN PF 100 UNITS/ML INJ",0250,J1642,9999107599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,3.5,fee schedule,""
"BETHANECHOL PO SUSP 0.5 MG/1 ML",0250,A9270,99999360199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,16.56 ,11.59 ,Aetna,"AETNA",7.45,45,percent of total billed charges,999999999,0.03087,11.592,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAPTOPRIL PO SUSP 1 MG/1 ML",0250,A9270,99999351499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,257.00 ,179.90 ,Aetna,"AETNA",115.65,45,percent of total billed charges,999999999,0.03087,179.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAPTOPRIL PO SUSP 0.1 MG/1 ML (NICU)",0250,A9270,99999644299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.52 ,3.86 ,Aetna,"AETNA",2.48,45,percent of total billed charges,999999999,0.03087,3.864,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE (ICN) PO SOLN 1 MG/1 ML",0250,A9270,99999366899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ML,,5.56 ,3.89 ,Aetna,"AETNA",2.50,45,percent of total billed charges,999999999,0.03087,3.892,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MBX (MAALOX PLUS-DIPHENHYDRAMINE-LIDOCAINE) ORAL SUSP CUP",0250,A9270,99999368499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRIL PO SUSP  0.1 MG/1 ML",0250,A9270,99999644899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.67 ,8.87 ,Aetna,"AETNA",5.70,45,percent of total billed charges,999999999,0.03087,8.869,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRIL PO SUSP 1 MG/1 ML",0250,A9270,99999644799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.10 ,7.77 ,Aetna,"AETNA",5.00,45,percent of total billed charges,999999999,0.03087,7.77,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GANCICLOVIR PO SOLN  25 MG/1 ML",0250,A9270,99999676199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,1104.48 ,773.14 ,Aetna,"AETNA",497.02,45,percent of total billed charges,999999999,0.03087,773.136,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCHLOROTHIAZIDE PO SUSP  5 MG/1 ML (NICU/PEDS)",0250,,99999675999,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCORTISONE PO SUSP 2 MG/1 ML (NICU)",0250,A9270,99999648999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4312.50 ,3018.75 ,Aetna,"AETNA",1940.63,45,percent of total billed charges,999999999,0.03087,3018.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOPHYLLINE PO SOLN 5 MG/1 ML",0250,A9270,99999586399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDOMETHACIN PO SOLN 1 MG/1 ML",0250,A9270,99999115799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.04 ,7.73 ,Aetna,"AETNA",4.97,45,percent of total billed charges,999999999,0.03087,7.728,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LANSOPRAZOLE-NAHCO3 PO SUSP 3 MG/ML (NICU/PEDS)",0250,A9270,99999666299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,390.00 ,273.00 ,Aetna,"AETNA",175.50,45,percent of total billed charges,999999999,0.03087,273,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM PO SUSP 1 MG/ML (NICU/PEDS)",0250,A9270,99999708999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MANNITOL 10% ORAL SOLN",0250,A9270,99999526899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE PO SOLN 1 MG/1 ML",0250,A9270,99999694499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOLAZONE PO SUSP 1 MG/1 ML",0250,A9270,99999530599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE PO SUSP 50 MG/1 ML",0250,A9270,99999714999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.65 ,6.06 ,Aetna,"AETNA",3.89,45,percent of total billed charges,999999999,0.03087,6.055,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMEPRAZOLE PO SUSP 2 MG/ML",0250,A9270,99999676899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,6.52 ,4.56 ,Aetna,"AETNA",2.93,45,percent of total billed charges,999999999,0.03087,5.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMEPRAZOLE PO SUSP 2 MG/ML",0250,A9270,99999014299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,7.60 ,5.32 ,Aetna,"AETNA",3.42,45,percent of total billed charges,999999999,0.03087,5.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMEPRAZOLE PO SUSP 2 MG/ML",0250,A9270,65628027210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.43 ,3.80 ,Aetna,"AETNA",2.44,45,percent of total billed charges,999999999,0.03087,5.32,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM ACETATE PO SOLN 2 MEQ/1 ML (NICU)",0250,A9270,99999659199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE PO SOLN 2 MEQ/1 ML (NICU/PEDS)",0250,A9270,99999581699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE PO SOLN 2.5 MEQ/1 ML (NICU)",0250,,99999612199,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE PO SUSP 5 MG/1 ML",0250,A9270,99999006899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"URSODIOL PO SUSP 30 MG/1 ML",0250,A9270,99999646999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,0.03087,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"URSODIOL PO SUSP  60 MG/1 ML",0250,A9270,99999646899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,21.50 ,15.05 ,Aetna,"AETNA",9.68,45,percent of total billed charges,999999999,0.03087,15.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN 50 MG/ML PO SOLN",0250,A9270,99999588599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE NASAL DROPS 0.125 %",0250,,56184012105,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,28.35 ,19.85 ,Aetna,"AETNA",12.76,45,percent of total billed charges,999999999,8.505,19.845,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN EYE DROPS 50 MG/1 ML",0250,,99999522399,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,5.32 ,3.72 ,Aetna,"AETNA",2.39,45,percent of total billed charges,999999999,1.596,3.724,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GENTAMICIN FORTIFIED OPHTH DROPS 14 MG/ 1 ML",0250,A9270,99999522499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,13.86 ,9.70 ,Aetna,"AETNA",6.24,45,percent of total billed charges,999999999,0.03087,9.702,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN FORTIFIED OPHTH DROPS 1.5% (15 MG/ML)",0250,,99999550899,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN FORTIFIED OPHTH DROPS 25 MG/ 1 ML",0250,,99999596799,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,27.29 ,19.10 ,Aetna,"AETNA",12.28,45,percent of total billed charges,999999999,8.187,19.103,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDO-EPINEPHRINE-TETRACAINE TOP GEL",0250,,71266629001,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,96.00 ,67.20 ,Aetna,"AETNA",43.20,45,percent of total billed charges,999999999,28.8,67.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTAZIDIME INTRAOCULAR 2 MG/0.1 ML INJ",0250,,99999678899,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,71.16 ,49.81 ,Aetna,"AETNA",32.02,45,percent of total billed charges,999999999,21.348,49.812,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL PO SOLN 10 MG/ML (NICU)",0250,A9270,99999193399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALTEPLASE 0.5 MG/ML INJ",0250,J2997,99999700999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,220.74 ,154.52 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,66.222,169.6462,fee schedule,""
"DEXAMETHASONE INJ (ICN) 0.1 MG/ML",0250,J1100,99999706799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.74 ,4.02 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,4.018,fee schedule,""
"INSULIN REGULAR HUMAN 100 UNIT/ML",0250,J1815,99999585999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,10.50 ,7.35 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,7.35,fee schedule,""
"HEPARIN-LIDOCAINE-NS (NICU)",0250,,99999690699,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GI COCKTAIL (HYOSCYAMINE-MAALOX-LIDO VISC)",0250,A9270,99999014099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RALLY BAG 1000ML INFUSION",0250,,99999581999,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,23.24 ,16.27 ,Aetna,"AETNA",10.46,45,percent of total billed charges,999999999,6.972,16.268,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOBARBITAL INJ 5 MG/ML (NICU)",0250,J2515,99999375399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,90.00 ,63.00 ,Aetna,"AETNA",121.07,191,fee schedule,999999999,20.37,121.0749,fee schedule,""
"KCL 20 MEQ IN LACTATED RINGERS IV SOLN",0250,,99999712199,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN ENEMA",0250,A9270,99999588999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,18.76 ,13.13 ,Aetna,"AETNA",8.44,45,percent of total billed charges,999999999,0.03087,13.132,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCRALFATE 4% IN AQUAPHOR EX OINT",0250,A9270,99999626499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,GR,,89.40 ,62.58 ,Aetna,"AETNA",40.23,45,percent of total billed charges,999999999,0.03087,62.58,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN INTRAOCULAR 1 MG/0.1 ML INJ",0250,,99999678799,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,15.40 ,10.78 ,Aetna,"AETNA",6.93,45,percent of total billed charges,999999999,4.62,10.78,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CENOBAMATE 25 MG PO TABS",0250,A9270,99999048899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.10 ,17.57 ,Aetna,"AETNA",11.30,45,percent of total billed charges,999999999,0.03087,17.57,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CENOBAMATE 12.5 MG PO TABS",0250,A9270,99999048999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,25.10 ,17.57 ,Aetna,"AETNA",11.30,45,percent of total billed charges,999999999,0.03087,17.57,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAT EMULSION 20% 50 ML ICN",0250,,99999118399,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,20.30 ,14.21 ,Aetna,"AETNA",9.14,45,percent of total billed charges,999999999,6.09,14.21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MISOPROSTOL 25 MCG PER 1/4 TAB",0250,A9270,99999719299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FUROSEMIDE 3 MG/1.5ML INJ SYRINGE (NICU)",0250,J1940,99999719399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.17,191,fee schedule,999999999,0.5,3.5,fee schedule,""
"HEPARIN 1000 UNITS/ML OR USE ONLY",0250,J1644,63323054015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.402,fee schedule,""
"HEPARIN 1000 UNITS/ML OR USE ONLY",0250,J1644,63323054031,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.86 ,24.40 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.402,fee schedule,""
"INSULIN (REGULAR) 0.5 UNIT/ML VIAL (NICU)",0250,A9270,9999972799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ML,,8.31 ,5.82 ,Aetna,"AETNA",3.74,45,percent of total billed charges,999999999,0.03087,5.817,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN (REGULAR) 1 UNIT/ML VIAL (NICU)",0250,A9270,99999724899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,9.31 ,6.52 ,Aetna,"AETNA",4.19,45,percent of total billed charges,999999999,0.03087,6.517,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOCARNITINE 200 MG/ML INJ (NICU)",0250,J1955,99999682899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,8.78 ,6.15 ,Aetna,"AETNA",67.12,191,fee schedule,999999999,2.634,67.1174,fee schedule,""
"LORAZEPAM 0.2 MG/ML INJ SOLN (NICU/PEDS)",0250,J2060,99999375499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.83,191,fee schedule,999999999,0.85,3.5,fee schedule,""
"HEPATITIS B VACCINE INJ SUSP (STATE SUPPLIED)",0250,90743,58160082052,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPATITIS B VACCINE INJ SUSP (STATE SUPPLIED)",0250,90743,58160082043,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMPICILLIN-SULBACTAM PEDS (PER AMPICILLIN CONTENT)",0250,J0295,10019063101A,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.5,GR,,33.22 ,23.25 ,Aetna,"AETNA",4.05,191,fee schedule,999999999,1.769,23.254,fee schedule,""
"PIPERACILLIN-TAZOBACTAM PEDS (PIPERACILLIN CONTENT)",0250,J2543,00206885216A,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.125,GR,,17.75 ,12.43 ,Aetna,"AETNA",2.01,191,fee schedule,999999999,0.89,12.425,fee schedule,""
"PROPRANOLOL PO SUSP 1 MG/ML",0250,A9270,99999698799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DTAP-IPV-HIB VACCINE (STATE SUPPLIED)",0250,90698,49281051005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE PREMIX (PEDS)",0250,J1836,00338105548,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,11.90 ,8.33 ,Aetna,"AETNA",0.06,191,fee schedule,999999999,0.02,8.33,fee schedule,""
"SILDENAFIL 2.5 MG/ML PO SUSP",0250,A9270,99999727499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,324.16 ,226.91 ,Aetna,"AETNA",145.87,45,percent of total billed charges,999999999,0.03087,226.912,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN 1 G INJ/SWFI PREMIX SYRINGE",0250,J0690,99999710699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,14.00 ,9.80 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,9.8,fee schedule,""
"HYDROCORTISONE INJ PER 10 MG (NICU)",0250,,99999732599,RC,,NDC,FACILITY,OUTPATIENT,10,ME,,14.84 ,10.39 ,Aetna,"AETNA",6.68,45,percent of total billed charges,999999999,4.452,10.388,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TACROLIMUS 1 MG/ML ORAL SUSP",0250,J7507,99999733699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.236,3.5,fee schedule,""
"TACROLIMUS 0.5 MG/ML ORAL SUSP",0250,J7507,99999733999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,15.60 ,10.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.236,10.92,fee schedule,""
"FENTANYL 10 MCG/ML 10 ML VIAL",0250,J3010,99999022599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"HEPARIN PF 100 UNITS/ML PEDS/PICU USE ONLY",0250,J1642,08881591125A,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.016,3.5,fee schedule,""
"NSS BOLUS INJ (NICU)",0250,,0829009410A,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,4.704,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NSS BOLUS INJ (NICU)",0250,,00409488803,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,6.72 ,4.70 ,Aetna,"AETNA",3.02,45,percent of total billed charges,999999999,1.2,4.704,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBUTEROL SULFATE (5 MG/ML) 0.5% INH (CONTINUOUS)",0250,J7611,65302052815,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,225.00 ,157.50 ,Aetna,"AETNA",0.31,191,fee schedule,999999999,0.12,157.5,fee schedule,""
"NITROGLYCERIN 2 MG IV SOLN",0250,J2305,99999742599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",2.75,191,fee schedule,999999999,1.286,3.5,fee schedule,""
"HYDROXYUREA 200 MG/ML ORAL SUSPENSION",0250,A9270,99999742899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONAZEPAM 0.1 MG/ML PO SUSPENSION",0250,A9270,99999062999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,120.00 ,84.00 ,Aetna,"AETNA",54.00,45,percent of total billed charges,999999999,0.03087,84,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPOETIN ALFA 2000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513012610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,192.04 ,134.43 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,134.428,fee schedule,""
"EPOETIN ALFA 3000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513026710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,288.07 ,201.65 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,201.649,fee schedule,""
"EPOETIN ALFA 4000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513014801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,357.77 ,250.44 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,268.87,fee schedule,""
"EPOETIN ALFA 4000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513014810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,384.10 ,268.87 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,268.87,fee schedule,""
"EPOETIN ALFA 10000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513014401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,894.41 ,626.09 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,630,fee schedule,""
"EPOETIN ALFA 10000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,55513014410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,900.00 ,630.00 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,630,fee schedule,""
"EPOETIN ALFA 40000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,59676034000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,2498.80 ,1749.16 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,1825.712,fee schedule,""
"EPOETIN ALFA 40000 UNIT/ML INJ SOLN NON-ESRD",0250,J0885,59676034001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,2608.16 ,1825.71 ,Aetna,"AETNA",15.80,191,fee schedule,999999999,6.88,1825.712,fee schedule,""
"SODIUM CHLORIDE 0.675% IV SOLN",0250,,9999888899,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.20 ,5.04 ,Aetna,"AETNA",3.24,45,percent of total billed charges,999999999,2.16,5.04,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARBEPOETIN ALFA 100 MCG/0.5ML INJ SOLN NON-ESRD",0250,J0881,55513002504,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3000.00 ,2100.00 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,2100,fee schedule,""
"DARBEPOETIN ALFA 200 MCG/0.4ML INJ SOLN NON-ESRD",0250,J0881,55513002801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,4523.37 ,3166.36 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,3166.359,fee schedule,""
"DARBEPOETIN ALFA 40 MCG/0.4ML INJ SOLN NON-ESRD",0250,J0881,55513002101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1349.50 ,944.65 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,1055.453,fee schedule,""
"DARBEPOETIN ALFA 40 MCG/0.4ML INJ SOLN NON-ESRD",0250,J0881,55513002104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,1507.79 ,1055.45 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,1055.453,fee schedule,""
"DARBEPOETIN ALFA 60 MCG/0.3ML INJ SOLN NON-ESRD",0250,J0881,55513002301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2024.14 ,1416.90 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,1583.183,fee schedule,""
"DARBEPOETIN ALFA 60 MCG/0.3ML INJ SOLN NON-ESRD",0250,J0881,55513002304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2261.69 ,1583.18 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,1583.183,fee schedule,""
"LEVOTHYROXINE SODIUM 100 MCG INJ SOLR (CUSTOM)",0250,,6332364907A,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,309.78 ,216.85 ,Aetna,"AETNA",139.40,45,percent of total billed charges,999999999,92.934,216.846,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN-HEPARIN 2 MG-10 UNITS/ML CATHETER SOLUTION",0250,J1644,9993900277,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3,ML,,35.00 ,24.50 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.5,fee schedule,""
"ALLOPURINOL 20 MG/ML ORAL SUSP",0250,A9270,99999012399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,31.50 ,22.05 ,Aetna,"AETNA",14.18,45,percent of total billed charges,999999999,0.03087,22.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 12 MG/50ML IVPB (PRE-MIX)",0250,J1100,9999000499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.23,191,fee schedule,999999999,0.119,3.5,fee schedule,""
"DIPHENHYDRAMINE 25 MG/50ML IVPB (PRE-MIX)",0250,J1200,9999000699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.804,3.5,fee schedule,""
"DIPHENHYDRAMINE 50 MG/50ML IVPB (PRE-MIX)",0250,J1200,9999000799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,7.58 ,5.31 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.804,5.306,fee schedule,""
"MIDAZOLAM 125 MG/125 ML INFUSION",0250,J2250,9999001199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,57.75 ,40.43 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,40.425,fee schedule,""
"TETANUS-DIPHTH-ACELL PERTUSSIS - STATE SUPPLIED",0250,90715,58160084252,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETANUS-DIPHTH-ACELL PERTUSSIS - STATE SUPPLIED",0250,90715,58160084243,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIRACLE MOUTH WASH",0250,A9270,9999004099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN ASPART (NOVOLOG) 1 UNIT/ML VIAL (NICU)",0250,J1815,09999005999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,5.6,fee schedule,""
"ISRADIPINE 1 MG/ML ORAL SUSPENSION (COMPOUND)",0250,A9270,9999006199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,90.00 ,63.00 ,Aetna,"AETNA",40.50,45,percent of total billed charges,999999999,0.03087,63,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLYBURIDE 1 MG/ML ORAL SUSPENSION (COMPOUND)",0250,A9270,9999006499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.20 ,5.04 ,Aetna,"AETNA",3.24,45,percent of total billed charges,999999999,0.03087,5.04,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIODARONE 5 MG/ML ORAL SUSPENSION (COMPOUND)",0250,A9270,9999006599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,672.00 ,470.40 ,Aetna,"AETNA",302.40,45,percent of total billed charges,999999999,0.03087,470.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARBEPOETIN ALFA 500 MCG/ML INJ SOLN NON-ESRD",0250,J0881,55513003201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,11308.44 ,7915.91 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,7915.908,fee schedule,""
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY-STATE SUPPLIED",0250,90686,58160090941,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INFLUENZA VAC SPLIT QUAD 0.5 ML IM SUSY-STATE SUPPLIED",0250,90686,58160090952,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN 1000 MG/250ML NS IVPB (PREMIX)",0250,J3370,99999010899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,90.00 ,63.00 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,63,fee schedule,""
"VANCOMYCIN 1500 MG/250ML NS IVPB (PREMIX)",0250,J3370,99999010999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,47.25 ,33.08 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,33.075,fee schedule,""
"VANCOMYCIN 2000 MG/500ML NS IVPB (PREMIX)",0250,J3370,99999011199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,70.00 ,49.00 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,49,fee schedule,""
"NIRSEVIMAB-ALIP 100 MG/ML IM (STATE SUPPLIED)",0250,90381,49281057415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIRSEVIMAB-ALIP 100 MG/ML IM (STATE SUPPLIED)",0250,90381,49281057488,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENZOCAINE-MENTHOL LOZENGE",0250,A9270,00904625549,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN TABLET RENOWN (POST-OP VTE PROPHYLAXIS)",0250,A9270,50458058010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN TABLET RENOWN (ATRIAL FIBRILLATION)",0250,A9270,50458057910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALVIMOPAN 12 MG PO CAPS (RWN)",0250,A9270,67919002010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,909.20 ,636.44 ,Aetna,"AETNA",409.14,45,percent of total billed charges,999999999,0.03087,636.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIRSEVIMAB-ALIP 50 MG/0.5 ML IM (STATE SUPPLIED)",0250,90380,49281057500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIRSEVIMAB-ALIP 50 MG/0.5 ML IM (STATE SUPPLIED)",0250,90380,49281057515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAZOLAMIDE 25 MG/ML ORAL SUSP",0250,A9270,09999013299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1380.00 ,966.00 ,Aetna,"AETNA",621.00,45,percent of total billed charges,999999999,0.03087,966,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MISOPROSTOL 200 MCG TABLET (RWN)",0250,A9270,43386016106,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,21.55 ,15.09 ,Aetna,"AETNA",9.70,45,percent of total billed charges,999999999,0.03087,15.085,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYTOCIN 0.02 UNITS/ML IN LR INFUSION (RWN)",0250,J2590,99999058899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,21.00 ,14.70 ,Aetna,"AETNA",3.21,191,fee schedule,999999999,1.4,14.7,fee schedule,""
"SELENIUM 2 MCG/ML IV SOLN (COMPOUNDED)",0250,,99999013999,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,188.10 ,131.67 ,Aetna,"AETNA",84.65,45,percent of total billed charges,999999999,56.43,131.67,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOCAPROIC ACID (AMICAR) SOLUTION FOR MOUTH SWAB",0250,A9270,99999771699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZATHIOPRINE 25 MG HALF TABS",0250,J7500,99999014499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.89,191,fee schedule,999999999,1.5,13.7,fee schedule,""
"HYDRALAZINE PO SOLN 4 MG/ML",0250,A9270,99999014799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RABIES IMMUNE GLOBULIN 300 UNIT/2ML INJ SOLN (>12 MO - 11 YR)",0250,90377,76125015002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,UN  ,,2186.80 ,1530.76 ,Aetna,"AETNA",984.06,45,percent of total billed charges,999999999,546.7,1530.76,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 0.5 MEQ/ML MOUTH RINSE",0250,A9270,99999015999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR (SPLIT DOSING PROTOCOL)",0250,,10572010101,RC,,NDC,FACILITY,OUTPATIENT,4000,ML,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR (SPLIT DOSING PROTOCOL)",0250,,52268010001,RC,,NDC,FACILITY,OUTPATIENT,4000,ML,,144.00 ,100.80 ,Aetna,"AETNA",64.80,45,percent of total billed charges,999999999,21.6,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 50 MCG/ML INFUSION",0250,J3010,00409909461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"FENTANYL 50 MCG/ML INFUSION",0250,J3010,99999018799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"MORPHINE 1 MG/ML IN 50 ML",0250,J2270,99999018899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,35.00 ,24.50 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"MORPHINE 1 MG/ML IN 50 ML",0250,J2270,70092112735,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,102.00 ,71.40 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"SODIUM ACETATE PO SOLN 2 MEQ/1 ML (NICU)",0250,A9270,99999018999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,44.10 ,30.87 ,Aetna,"AETNA",19.85,45,percent of total billed charges,999999999,0.03087,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NICU UAC FLUID (HEPARIN 1 UNIT/ML-0.45% NA ACET IN 100 ML)",0250,,99999019299,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VANCOMYCIN 1750 MG/500ML NS IVPB (PREMIX)",0250,J3370,99999033299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,90.00 ,63.00 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,63,fee schedule,""
"MORPHINE PCA (PEDS)",0250,J2270,99999018899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,35.00 ,24.50 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"MORPHINE PCA (PEDS)",0250,J2270,70092112735,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,102.00 ,71.40 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"ATEZOLIZUMAB 1200 MG/20ML IV SOLN",0250,J9022,50242091701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,31696.86 ,22187.80 ,Aetna,"AETNA",160.33,191,fee schedule,999999999,82.07,22187.802,fee schedule,""
"DILTIAZEM HYDROCHLORIDE 2 % TOPICAL GEL (COMPOUNDED)",0250,A9270,99999021599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN SULFATE 25 MG/ML ORAL SUSPENSION",0250,A9270,9999000299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROMORPHONE 1 MG/ML IN NS 50 ML BAG (NON-STANDARD PCA)",0250,J1170,99999022199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,35.00 ,24.50 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,24.5,fee schedule,""
"HYDROMORPHONE 2 MG/ML IN NS 50 ML BAG (NON-STANDARD PCA)",0250,J1170,99999022299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,49.00 ,34.30 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,34.3,fee schedule,""
"KETAMINE 25MG/50ML IVPB LOW DOSE PAIN INFUSION",0250,,99999022899,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE 0.1 MG/ML ORAL SOLN (NICU)",0250,A9270,99999023299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLECAINIDE 20 MG/ML ORAL SUSPENSION (NICU/PEDS)",0250,A9270,99999024299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,0.03087,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ON-Q PUMP 270 ML",0250,A4306,93494013672,RC,HCPCS,NDC,FACILITY,OUTPATIENT,270,ML,,756.00 ,529.20 ,Aetna,"AETNA",340.20,45,percent of total billed charges,999999999,189,529.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ON-Q PUMP 400 ML",0250,A4306,93494013472,RC,HCPCS,NDC,FACILITY,OUTPATIENT,400,ML,,1375.00 ,962.50 ,Aetna,"AETNA",618.75,45,percent of total billed charges,999999999,343.75,962.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANTICOAGULANT CIT DEXT SOLN A VI 10 ML VIAL",0250,,99999024599,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZITHROMYCIN 500 MG IN D5W 250 ML PREMIX",0250,J0456,99999024899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,49.00 ,34.30 ,Aetna,"AETNA",4.60,191,fee schedule,999999999,1.79,34.3,fee schedule,""
"REMIFENTANIL 1 MG IN 100 ML NS (10 MCG/ML) PCA INFUSION",0250,,99999025499,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,336.59 ,235.61 ,Aetna,"AETNA",151.47,45,percent of total billed charges,999999999,100.977,235.613,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ONDANSETRON 16 MG/50 ML D5W IV (PREMIX)",0250,J2405,99999025599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,28.00 ,19.60 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.09,19.6,fee schedule,""
"CEFTRIAXONE 2 G INJ/SWFI SYRINGE",0250,J0696,99999026199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,70.00 ,49.00 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,49,fee schedule,""
"ASPIRIN ORAL SUSPENSION 1 MG/ML",0250,A9270,99999025699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,0.03087,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFEPIME 2 G INJ/D5W IV SYRINGE (PREMIX)",0250,J0692,99999025899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,36.12 ,25.28 ,Aetna,"AETNA",2.56,191,fee schedule,999999999,1.23,25.284,fee schedule,""
"CEFTRIAXONE 1 G INJ/SWFI SYRINGE",0250,J0696,99999700499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,49.00 ,34.30 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,34.3,fee schedule,""
"MORPHINE 1 MG/ML IN NS (CONTINUOUS INFUSION) (PEDS)",0250,J2270,99999018899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,35.00 ,24.50 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"MORPHINE 1 MG/ML IN NS (CONTINUOUS INFUSION) (PEDS)",0250,J2270,70092112735,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,102.00 ,71.40 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"CEFAZOLIN 2 G INJ/NSS PREMIX SYRINGE",0250,J0690,99999026499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.53 ,8.77 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,8.771,fee schedule,""
"FENTANYL 50 MCG/ML PCA (PEDS)",0250,J3010,00409909461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"FENTANYL 50 MCG/ML PCA (PEDS)",0250,J3010,99999018799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"HYALURONIDASE 15 UNITS/ML INJ (FOR EXTRAVASATION)",0250,J3473,99999027699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,UN  ,,37.25 ,26.08 ,Aetna,"AETNA",0.69,191,fee schedule,999999999,0.36,26.075,fee schedule,""
"PHENTOLAMINE MESYLATE 0.5 MG/ML (FOR EXTRAVASATION)",0250,J2760,99999028399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,897.48 ,628.24 ,Aetna,"AETNA",848.65,191,fee schedule,999999999,269.244,848.6512,fee schedule,""
"NITROGLYCERIN 2% OINTMENT (FOR EXTRAVASATION)",0250,A9270,99999028899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,14.36 ,10.05 ,Aetna,"AETNA",6.46,45,percent of total billed charges,999999999,0.03087,10.052,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE PCA",0250,J2270,99999018899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,35.00 ,24.50 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"MORPHINE PCA",0250,J2270,70092112735,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,102.00 ,71.40 ,Aetna,"AETNA",8.52,191,fee schedule,999999999,2.97,71.4,fee schedule,""
"FENTANYL 50 MCG/ML PCA",0250,J3010,00409909461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"FENTANYL 50 MCG/ML PCA",0250,J3010,99999018799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,49,fee schedule,""
"PENICILLIN G POTASSIUM 25000 UNIT/ML IN NS 100 ML IVPB",0250,J2540,99999018499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,600000,UN  ,,134.94 ,94.46 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.771,94.458,fee schedule,""
"HYDROMORPHONE 1 MG/ML IN NS 50 ML BAG (NON-STANDARD CONTINUOUS INFUSION)",0250,J1170,99999022199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,35.00 ,24.50 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,24.5,fee schedule,""
"HYDROMORPHONE 2 MG/ML IN NS 50 ML BAG (NON-STANDARD CONTINUOUS INFUSION)",0250,J1170,99999022299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,49.00 ,34.30 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,34.3,fee schedule,""
"HYDROMORPHONE 0.2 MG/ML IN NS 50 ML PCA (PEDS)",0250,J1170,70004030030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,70.00 ,49.00 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,49,fee schedule,""
"HYDROMORPHONE 0.2 MG/ML IN NS 50 ML (CONTINUOUS INFUSION)",0250,J1170,70004030030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,70.00 ,49.00 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,49,fee schedule,""
"HYDROMORPHONE 0.2 MG/ML IN NS 50 ML PCA",0250,J1170,70004030030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,70.00 ,49.00 ,Aetna,"AETNA",9.09,191,fee schedule,999999999,3.47,49,fee schedule,""
"VALPROIC ACID 100 MG/ML INJ - MIGRAINE",0250,J3490,63323049405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,12.64 ,8.85 ,Aetna,"AETNA",5.69,45,percent of total billed charges,999999999,0,8.848,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MERCAPTOPURINE 25 MG PO HALF TAB",0250,A9270,99999029999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.75 ,4.03 ,Aetna,"AETNA",2.59,45,percent of total billed charges,999999999,0.03087,4.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN (PEDS)",0250,A9270,00121231650,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,35.70 ,24.99 ,Aetna,"AETNA",16.07,45,percent of total billed charges,999999999,0.03087,24.99,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIVAROXABAN 2.5 MG PO TABS",0250,A9270,50458057710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OMALIZUMAB 75 MG/0.5ML SC SOSY",0250,J2357,50242021401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,2759.40 ,1931.58 ,Aetna,"AETNA",70.31,191,fee schedule,999999999,38.65,1931.58,fee schedule,""
"CLONIDINE PO SUSP 20 MCG/ML (NICU)",0250,A9270,99999033099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,174.00 ,121.80 ,Aetna,"AETNA",78.30,45,percent of total billed charges,999999999,0.03087,121.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NALOXONE PO SOLN 2 MG/2 ML",0250,J2310,76329336901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,213.85 ,149.70 ,Aetna,"AETNA",15.39,191,fee schedule,999999999,7.288,149.695,fee schedule,""
"VANCOMYCIN 1250 MG/250ML NS IVPB (PREMIX)",0250,J3370,99999033799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,90.00 ,63.00 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,63,fee schedule,""
"ZINC SULFATE 0.5 MG/ML ALIQUOT (NICU)",0250,,99999034199,RC,,NDC,FACILITY,OUTPATIENT,40,ML,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG IV SOLR",0250,J9358,65597040601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8074.80 ,5652.36 ,Aetna,"AETNA",52.09,191,fee schedule,999999999,25.21,5652.36,fee schedule,""
"HEPARIN IN NACL 25000-0.45 UT/500ML INFUSION ANTI-XA CALCULATOR",0250,J1644,00409765103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,38.50 ,26.95 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,26.95,fee schedule,""
"HEPARIN IN NACL 25000-0.45 UT/500ML INFUSION ANTI-XA CALCULATOR",0250,J1644,00409765113,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,31.50 ,22.05 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,26.95,fee schedule,""
"VINCRISTINE SULFATE 1MG/ML FOR HIGH DOSE REGIMEN ONLY",0250,J9370,61703030906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,45.36 ,31.75 ,Aetna,"AETNA",15.11,191,fee schedule,999999999,4.88,50.736,fee schedule,""
"VINCRISTINE SULFATE 1MG/ML FOR HIGH DOSE REGIMEN ONLY",0250,J9370,61703030916,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,72.48 ,50.74 ,Aetna,"AETNA",15.11,191,fee schedule,999999999,4.88,50.736,fee schedule,""
"EPOETIN ALFA-EPBX 2000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,109.10 ,76.37 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,76.37,fee schedule,""
"EPOETIN ALFA-EPBX 2000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,109.10 ,76.37 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,76.37,fee schedule,""
"EPOETIN ALFA-EPBX 3000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,163.66 ,114.56 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,114.562,fee schedule,""
"EPOETIN ALFA-EPBX 3000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,163.66 ,114.56 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,114.562,fee schedule,""
"EPOETIN ALFA-EPBX 4000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,218.21 ,152.75 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,152.747,fee schedule,""
"EPOETIN ALFA-EPBX 4000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,218.21 ,152.75 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,152.747,fee schedule,""
"EPOETIN ALFA-EPBX 10000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,545.53 ,381.87 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,381.871,fee schedule,""
"EPOETIN ALFA-EPBX 10000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,545.53 ,381.87 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,381.871,fee schedule,""
"EPOETIN ALFA-EPBX 40000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,1818.43 ,1272.90 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,1272.901,fee schedule,""
"EPOETIN ALFA-EPBX 40000 UNIT/ML INJ SOLN NON-ESRD",0250,Q5106,00069130904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,1818.43 ,1272.90 ,Aetna,"AETNA",14.34,191,fee schedule,999999999,7.25,1272.901,fee schedule,""
"HYDROXYCHLOROQUINE ORAL SUSPENSION 25 MG/ML",0250,A9270,99999040599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,0.03087,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REMDESIVIR 100 MG SOLN FOR INJECTION",0250,J0248,61958290102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",11.57,191,fee schedule,999999999,5.51,1750,fee schedule,""
"POVIDONE-IODINE 0.23 % ORAL SOLUTION (COMPOUND)",0250,A9270,99999041099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028523,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,21.35 ,14.95 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,14.945,fee schedule,""
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,10.86 ,7.60 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,14.945,fee schedule,""
"ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,10.86 ,7.60 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,14.945,fee schedule,""
"AMPHOTERICIN B 0.15% OPHTHALMIC SOLUTION (COMPOUND)",0250,A9270,99999041199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1781.50 ,1247.05 ,Aetna,"AETNA",801.68,45,percent of total billed charges,999999999,445.375,1247.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPARIN 50 UNIT/ML IN 0.45 NACL IV SYRINGE (PEDS)",0250,J1644,99999041399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,3.5,fee schedule,""
"AMPHOTERICIN B 5 MCG/0.1 ML INTRAOCULAR INJ (COMPOUND)",0250,A9270,99999041499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,200.82 ,140.57 ,Aetna,"AETNA",90.37,45,percent of total billed charges,999999999,50.205,140.574,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMPHOTERICIN B 10 MCG/0.1 ML INTRAOCULAR INJ (COMPOUND)",0250,A9270,99999041599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,200.82 ,140.57 ,Aetna,"AETNA",90.37,45,percent of total billed charges,999999999,50.205,140.574,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN K 100 MCG/ML PO SUSPENSION",0250,A9270,99999042999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,66.66 ,46.66 ,Aetna,"AETNA",30.00,45,percent of total billed charges,999999999,0.03087,46.662,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPINEPHRINE 1 MG/10ML INJ (NRP CODE NARRATOR ONLY)",0250,J0171,00409493301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,53.62 ,37.53 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,37.534,fee schedule,""
"EPINEPHRINE 1 MG/10ML INJ (NRP CODE NARRATOR ONLY)",0250,J0171,00409493311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,48.79 ,34.15 ,Aetna,"AETNA",1.55,191,fee schedule,999999999,0.73,37.534,fee schedule,""
"MORPHINE SULFATE (PF) 0.5 MG/ML INJ SOLN (NICU)",0250,J2274,99999020999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.80 ,4.06 ,Aetna,"AETNA",27.56,191,fee schedule,999999999,1.74,27.5613,fee schedule,""
"VASOPRESSIN 20 UNITS/100 ML NS PREMIX",0250,J2598,99999043699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,300.00 ,210.00 ,Aetna,"AETNA",3.59,191,fee schedule,999999999,1.815,210,fee schedule,""
"PHENYLEPHRINE 40 MG/250 ML NS PREMIX",0250,J2371,99999043799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,mcg,,70.00 ,49.00 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.01,49,fee schedule,""
"POTASSIUM PHOSPHATE 30 MMOL/500 ML D5W PREMIX",0250,,99999043999,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 150 MEQ/1000 ML D5W PREMIX",0250,,99999044099,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,156.90 ,109.83 ,Aetna,"AETNA",70.61,45,percent of total billed charges,999999999,47.07,109.83,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MERCAPTOPURINE 25 MG/ML ORAL SUSPENSION",0250,A9270,99999044799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,86.16 ,60.31 ,Aetna,"AETNA",38.77,45,percent of total billed charges,999999999,0.03087,60.312,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002771401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,107.89 ,75.52 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,""
"INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002771459,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,""
"INSULIN LISPRO (0.5 UNIT DIAL) 100 UNIT/ML SC SOPN",0250,J1815,00002775205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,""
"ALTEPLASE INJ 5 MG/5 ML",0250,J2997,99999044999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2063.25 ,1444.28 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,1444.275,fee schedule,""
"VASOPRESSIN 1 UNIT/ML IV SOLN",0250,J2598,99999045099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,226.26 ,158.38 ,Aetna,"AETNA",3.59,191,fee schedule,999999999,1.815,158.382,fee schedule,""
"EPINEPHRINE 16 MG IN 0.9% NACL 500 ML IV SOLN",0250,,99999046099,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,63,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NOREPINEPHRINE 32 MG IN 0.9% NACL 500 ML IV SOLN",0250,,99999046199,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACLOFEN 5 MG/ML PO SUSP (NICU/PEDS)",0250,A9270,99999046499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,9.25 ,6.48 ,Aetna,"AETNA",4.16,45,percent of total billed charges,999999999,0.03087,6.475,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETHANOL 70% LOCK CATHETER SOLUTION",0250,,99999046599,RC,,NDC,FACILITY,OUTPATIENT,6.5,ML,,2840.00 ,1988.00 ,Aetna,"AETNA",1278.00,45,percent of total billed charges,999999999,852,1988,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TENECTEPLASE 50 MG IV FOR STROKE",0250,J3101,50242012047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,21228.00 ,14859.60 ,Aetna,"AETNA",292.44,191,fee schedule,999999999,143.87,14859.6,fee schedule,""
"ETESEVIMAB 700 MG/20ML IV SOLN",0250,Q0245,00002795001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2100,ME,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.003,0.01,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 5 MCG/ML VIAL FOR DILUTION",0250,J3010,00409909422,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.89,191,fee schedule,999999999,0.84,3.5,fee schedule,""
"MARGETUXIMAB-CMKB 250 MG/10ML IV SOLN",0250,J9353,74527002202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,6886.80 ,4820.76 ,Aetna,"AETNA",89.85,191,fee schedule,999999999,44.17,4820.76,fee schedule,""
"INSULIN GLARGINE 100 UNIT/ML SC SOLN (RWN)",0250,J1815,83257001411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,351.72 ,246.20 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,246.204,fee schedule,""
"INSULIN LISPRO 100 UNIT/ML INJ SOLN (RWN)",0250,J1815,00002753301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,108.77 ,76.14 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,76.139,fee schedule,""
"GANCICLOVIR 2 MG/0.1 ML INTRAOCULAR INJ",0250,,99999048399,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,108.64 ,76.05 ,Aetna,"AETNA",48.89,45,percent of total billed charges,999999999,32.592,76.048,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VORICONAZOLE 100 MCG/0.1 ML INTRAOCULAR INJ",0250,,99999048499,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,9.70 ,6.79 ,Aetna,"AETNA",4.37,45,percent of total billed charges,999999999,2.91,6.79,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN-HEPARIN 10 MG-10 UNITS/ML CATHETER LOCK INJECTION",0250,,99999048699,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTAZIDIME-HEPARIN 10 MG-10 UNITS/ML CATHETER LOCK INJECTION",0250,,99999048799,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDRALAZINE 0.2 MG/ML IN NS INJECTION",0250,J0360,99999049099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,76.08 ,53.26 ,Aetna,"AETNA",10.62,191,fee schedule,999999999,5.587,53.256,fee schedule,""
"VORICONAZOLE FORTIFIED OPHTH DROPS 10 MG/ML",0250,,99999049399,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,166.26 ,116.38 ,Aetna,"AETNA",74.82,45,percent of total billed charges,999999999,49.878,116.382,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIGOXIN 25 MCG/ML IN NS INJ (NICU/PEDS)",0250,J1160,99999049599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,646.94 ,452.86 ,Aetna,"AETNA",17.30,191,fee schedule,999999999,9.408,452.858,fee schedule,""
"VORICONAZOLE 50 MCG/0.1 ML INTRAOCULAR INJ",0250,,99999049799,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,9.70 ,6.79 ,Aetna,"AETNA",4.37,45,percent of total billed charges,999999999,2.91,6.79,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINDAMYCIN 1 MG/0.1 ML INTRAOCULAR INJECTION",0250,,99999049899,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,29.82 ,20.87 ,Aetna,"AETNA",13.42,45,percent of total billed charges,999999999,8.946,20.874,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALTEPLASE 15 MCG/0.1ML INTRAOCULAR INJECTION",0250,J2997,99999050099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,742.80 ,519.96 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,519.96,fee schedule,""
"AZATHIOPRINE 12.5 MG QUARTER TABS",0250,J7500,99999050599,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.89,191,fee schedule,999999999,1.5,13.7,fee schedule,""
"ENALAPRILAT 25 MCG/ML IN NS INJ (NICU/PEDS)",0250,A9270,99999050699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.73 ,8.91 ,Aetna,"AETNA",5.73,45,percent of total billed charges,999999999,3.1825,8.911,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASCORBIC ACID 100 MG/ML ORAL SOLUTION (NICU/PEDS)",0250,,99999050899,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARBEPOETIN ALFA 300 MCG/0.6ML INJ SOLN NON-ESRD",0250,J0881,55513011101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,6785.07 ,4749.55 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,4749.549,fee schedule,""
"CHLOROTHIAZIDE 10 MG/ML IN NS INJ (NICU/PEDS)",0250,J1205,99999051899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,99.36 ,69.55 ,Aetna,"AETNA",167.62,191,fee schedule,999999999,29.808,167.6216,fee schedule,""
"INSULIN REGULAR 100 UNITS IN 100 ML NS PREMIX",0250,,99999052299,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,21.70 ,15.19 ,Aetna,"AETNA",9.77,45,percent of total billed charges,999999999,5.425,15.19,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DARBEPOETIN ALFA 150 MCG/0.3ML INJ SOSY NON-ESRD",0250,J0881,55513002701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3036.07 ,2125.25 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,2374.771,fee schedule,""
"DARBEPOETIN ALFA 150 MCG/0.3ML INJ SOSY NON-ESRD",0250,J0881,55513002704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,3392.53 ,2374.77 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,2374.771,fee schedule,""
"CEFTAZIDIME OPHTH DROPS 50 MG/1 ML",0250,J0713,99999052499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,21.10 ,14.77 ,Aetna,"AETNA",3.17,191,fee schedule,999999999,1.694,14.77,fee schedule,""
"KETAMINE 500 MG IN 250 ML 0.9% NACL INFUSION (PREMIX)",0250,,99999052799,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,12.6,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE 1000 MG IN 500 ML 0.9% NACL INFUSION (PREMIX)",0250,,99999052899,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,90.00 ,63.00 ,Aetna,"AETNA",40.50,45,percent of total billed charges,999999999,27,63,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE 500 MG/250ML 0.9% NACL LOW DOSE PAIN INFUSION (CONTINUOUS)",0250,,99999052799,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,12.6,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRANEXAMIC ACID 100 MG/ML FOR INHALATION (NEB)",0250,,81284061100,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,8.16 ,5.71 ,Aetna,"AETNA",3.67,45,percent of total billed charges,999999999,2.448,5.712,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRANEXAMIC ACID 100 MG/ML FOR INHALATION (NEB)",0250,,81284061110,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,8.16 ,5.71 ,Aetna,"AETNA",3.67,45,percent of total billed charges,999999999,2.448,5.712,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIXAGEVIMAB 150 MG/1.5 ML INJ SOLN",0250,Q0220,00310889501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,ME,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.003,0.01,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOXIDIL 1 MG/ML ORAL SUSPENSION (NICU/PEDS)",0250,A9270,99999054199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,0.03087,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXAMETHASONE 400 MCG/0.1 ML INTRAOCULAR INJ",0250,,99999054699,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,77.70 ,54.39 ,Aetna,"AETNA",34.97,45,percent of total billed charges,999999999,23.31,54.39,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPARACAINE 0.05% (0.5 MG/ML) FORTIFIED EYE DROPS",0250,,99999054899,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,11.34 ,7.94 ,Aetna,"AETNA",5.10,45,percent of total billed charges,999999999,3.402,7.938,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CINACALCET 5 MG/ML ORAL SUSPENSION (NICU/PEDS)",0250,A9270,99999055299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,0.03087,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPYLTHIOURACIL 5 MG/ML ORAL SUSPENSION",0250,A9270,99999057899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,22.80 ,15.96 ,Aetna,"AETNA",10.26,45,percent of total billed charges,999999999,0.03087,15.96,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERRIC GLUCONATE COMPLEX (DIALYSIS USE ONLY) 12.5 MG/ML IV SOLN",0250,J2916,00024279210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,355.32 ,248.72 ,Aetna,"AETNA",4.16,191,fee schedule,999999999,1.95,248.724,fee schedule,""
"FERRIC GLUCONATE COMPLEX (DIALYSIS USE ONLY) 12.5 MG/ML IV SOLN",0250,J2916,00143957001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,132.09 ,92.46 ,Aetna,"AETNA",4.16,191,fee schedule,999999999,1.95,248.724,fee schedule,""
"FERRIC GLUCONATE COMPLEX (DIALYSIS USE ONLY) 12.5 MG/ML IV SOLN",0250,J2916,00143957010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,113.47 ,79.43 ,Aetna,"AETNA",4.16,191,fee schedule,999999999,1.95,248.724,fee schedule,""
"DARBEPOETIN ALFA 25 MCG/0.42 ML INJ SOSY (NON-ESRD)",0250,J0881,55513005701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,900.00 ,630.00 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,659.666,fee schedule,""
"DARBEPOETIN ALFA 25 MCG/0.42 ML INJ SOSY (NON-ESRD)",0250,J0881,55513005704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,942.38 ,659.67 ,Aetna,"AETNA",5.54,191,fee schedule,999999999,2.86,659.666,fee schedule,""
"AMPICILLIN-HEPARIN 10 MG-10 UNITS/ML CATHETER LOCK INJECTION",0250,,99999060599,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOSENTAN 2 MG/ML ORAL SUSPENSION",0250,A9270,99999061499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,8,ML,,652.86 ,457.00 ,Aetna,"AETNA",293.79,45,percent of total billed charges,999999999,0.03087,457.002,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANASTROZOLE 0.5 MG HALF TABLET",0250,A9270,99999062299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,UN  ,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TAFASITAMAB-CXIX 200 MG/5ML IV ",0250,J9349,73535020801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,3969.69 ,2778.78 ,Aetna,"AETNA",25.94,191,fee schedule,999999999,12.97,2778.783,fee schedule,""
"QUETIAPINE 10 MG/ML ORAL SUSPENSION (NICU/PEDS)",0250,A9270,99999064299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,456.00 ,319.20 ,Aetna,"AETNA",205.20,45,percent of total billed charges,999999999,0.03087,319.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAMETINIB DIMETHYL SULFOXIDE 0.25 MG HALF-TABLET",0250,J8999,99999064399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,462.94 ,324.06 ,Aetna,"AETNA",208.32,45,percent of total billed charges,999999999,0,324.058,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RABIES IMMUNE GLOBULIN 300 UNIT/2ML INJ SOLN (31 DAYS - 12 MO)",0250,90377,76125015002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,UN  ,,2186.80 ,1530.76 ,Aetna,"AETNA",984.06,45,percent of total billed charges,999999999,546.7,1530.76,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RABIES IMMUNE GLOBULIN 300 UNIT/2ML INJ SOLN (</= 30 DAYS)",0250,90377,76125015002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,150,UN  ,,2186.80 ,1530.76 ,Aetna,"AETNA",984.06,45,percent of total billed charges,999999999,546.7,1530.76,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARVEDILOL 1 MG/ML ORAL SUSPENSION",0250,A9270,99999064799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,0.03087,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM PHOSPHATE 3 MMOL/ML ORAL SOLUTION (NICU)",0250,,99999066299,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,176.58 ,123.61 ,Aetna,"AETNA",79.46,45,percent of total billed charges,999999999,52.974,123.606,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALEMTUZUMAB 30 MG/ML IV SOLN",0250,J0202,58468035701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,0.01 ,0.01 ,Aetna,"AETNA",4483.88,191,fee schedule,999999999,0.003,4483.8778,fee schedule,""
"COVID-19 MRNA VAC 12Y OR OLDER PFIZER 30 MCG/0.3ML IM SUSP",0250,91320,00069236201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,159.93 ,111.95 ,Aetna,"AETNA",71.97,45,percent of total billed charges,999999999,39.9825,447.482,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COVID-19 MRNA VAC 12Y OR OLDER PFIZER 30 MCG/0.3ML IM SUSP",0250,91320,00069236210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.3,ML,,639.26 ,447.48 ,Aetna,"AETNA",287.67,45,percent of total billed charges,999999999,39.9825,447.482,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY (STATE-SUPPLIED)",0250,90677,00005200002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY (STATE-SUPPLIED)",0250,90677,00005200010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,0.01 ,0.01 ,Aetna,"AETNA",0.00,45,percent of total billed charges,999999999,0.0025,0.007,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SILDENAFIL 3.3 MG/50 ML D5W IV SYRINGE",0250,A9270,99999069899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,241.50 ,169.05 ,Aetna,"AETNA",108.68,45,percent of total billed charges,999999999,60.375,169.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIKACIN 2% (20 MG/ML) COMPOUNDED EYE DROPS",0250,,99999070499,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,16.80 ,11.76 ,Aetna,"AETNA",7.56,45,percent of total billed charges,999999999,5.04,11.76,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THIOGUANINE 20 MG/ML COMPOUNDED ORAL SUSPENSION",0250,,99999070899,RC,,NDC,FACILITY,OUTPATIENT,30,ML,,35820.00 ,25074.00 ,Aetna,"AETNA",16119.00,45,percent of total billed charges,999999999,6541,25074,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SOD CITRATE-CITRIC ACID 0.25 MEQ/ML PO SOLN (NICU)",0250,A9270,99999070999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,61.32 ,42.92 ,Aetna,"AETNA",27.59,45,percent of total billed charges,999999999,0.03087,42.924,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEG-KCL-NACL-NASULF-NA ASC-C 100 G PO SOLR (NO PROTOCOL LINKS)",0250,A9270,00093356026,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,187.14 ,131.00 ,Aetna,"AETNA",84.21,45,percent of total billed charges,999999999,0.03087,130.998,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPARIN 1000 UNIT/ML INTRACATHETER (FOR DIALYSIS USE)",0250,J1644,63323054005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,""
"HEPARIN 1000 UNIT/ML INTRACATHETER (FOR DIALYSIS USE)",0250,J1644,63323054015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,""
"HEPARIN 1000 UNIT/ML INTRACATHETER (FOR DIALYSIS USE)",0250,J1644,63323054033,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,""
"HEPARIN 1000 UNIT/ML INTRACATHETER (FOR DIALYSIS USE)",0250,J1644,63323054036,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.23 ,23.96 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,23.961,fee schedule,""
"FOLIC ACID 1 MG/ML PO SUSP (NICU/PEDS)",0250,A9270,99999072999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FOSAPREPITANT 150 MG IN 150 ML 0.9% NACL PREMIX",0250,,99999073299,RC,,NDC,FACILITY,OUTPATIENT,150,ML,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIFAXIMIN 200 MG PO TABS",0250,A9270,65649030141,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,75.72 ,53.00 ,Aetna,"AETNA",34.07,45,percent of total billed charges,999999999,0.03087,53.004,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZONISAMIDE 10MG/ML ORAL SUSPENSION",0250,A9270,99999029399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRANEXAMIC ACID 1000 MG/10ML (NASAL PACKING) ",0250,,81284061100,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRANEXAMIC ACID 1000 MG/10ML (NASAL PACKING) ",0250,,81284061110,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 8.4% FOR INHALATION",0250,J3490,99999068099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HEPARIN 25 UNITS/ML IN 500 ML D5W INFUSION (IMPELLA)",0250,J1644,99999045899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,23.28 ,16.30 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,16.296,fee schedule,""
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN (IMPELLA)",0250,J1644,63323054005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.402,fee schedule,""
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN (IMPELLA)",0250,J1644,63323054015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,12.74 ,8.92 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.402,fee schedule,""
"HEPARIN SODIUM (PORCINE) 1000 UNIT/ML INJ SOLN (IMPELLA)",0250,J1644,63323054031,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,UN  ,,34.86 ,24.40 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.26,24.402,fee schedule,""
"DOXYCYCLINE 5 MG/ML ORAL SUSPENSION (EMERGENCY USE)",0250,A9270,99999048199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,175.56 ,122.89 ,Aetna,"AETNA",79.00,45,percent of total billed charges,999999999,0.03087,122.892,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BEBTELOVIMAB 175 MG/2ML IV SOLN",0250,Q0222,00002758901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,175,ME,,0.01 ,0.01 ,Aetna,"AETNA",4813.20,191,fee schedule,999999999,0.003,4813.2,fee schedule,""
"LIDOCAINE 2% NEBULIZER SOLN (COUGH)",0250,,00143959401,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,5.068,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 2% NEBULIZER SOLN (COUGH)",0250,,00143959425,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,5.068,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARDIOPLEGIA SOLN 1000 ML (KCL 26 MEQ, MAG SULF 2 G) PREMIX",0250,,99999056999,RC,,NDC,FACILITY,OUTPATIENT,1017,ML,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,90,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFAZOLIN 2 G INJ/SWFI PREMIX SYRINGE",0250,J0690,99999057499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,11.90 ,8.33 ,Aetna,"AETNA",1.57,191,fee schedule,999999999,0.72,8.33,fee schedule,""
"OXYTOCIN 0.02 UNITS/ML IN LR INFUSION BOLUS (RWN)",0250,A9270,99999058899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,10.5,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYTOCIN 0.02 UNITS/ML IN LR INFUSION POSTPARTUM (RWN)",0250,A9270,99999058899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,5.25,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM GLUCONATE 100 MG/ML ORAL SOLUTION",0250,J0612,63323036019,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,65.87 ,46.11 ,Aetna,"AETNA",0.10,191,fee schedule,999999999,0.05,46.109,fee schedule,""
"NITROGLYCERIN 0.2 % PR OINTMENT",0250,A9270,99999061799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,338.94 ,237.26 ,Aetna,"AETNA",152.52,45,percent of total billed charges,999999999,0.03087,237.258,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BEVACIZUMAB-BVZR 1.25 MG/0.05 ML INTRAVITREAL INJECTION",0250,C9257,99999061999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,31.75 ,22.23 ,Aetna,"AETNA",4.56,191,fee schedule,999999999,1.99,22.225,fee schedule,""
"TRAMETINIB 0.1 MG/ML ORAL SOLUTION",0250,J8999,99999063699,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,430.26 ,301.18 ,Aetna,"AETNA",193.62,45,percent of total billed charges,999999999,0,602.385,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAMETINIB 0.1 MG/ML ORAL SOLUTION",0250,J8999,99999063799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,860.55 ,602.39 ,Aetna,"AETNA",387.25,45,percent of total billed charges,999999999,0,602.385,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZATHIOPRINE 50 MG/ML ORAL SYRINGE",0250,J7500,99999065199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.89,191,fee schedule,999999999,1.5,13.7,fee schedule,""
"AMILORIDE HCL 5 MG PO TABS",0250,A9270,49884011701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.86 ,4.80 ,Aetna,"AETNA",3.09,45,percent of total billed charges,999999999,0.03087,4.802,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX POWD",0250,A9270,00832046515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,27.62 ,19.33 ,Aetna,"AETNA",12.43,45,percent of total billed charges,999999999,0.03087,92.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX POWD",0250,A9270,68308015215,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,45.57 ,31.90 ,Aetna,"AETNA",20.51,45,percent of total billed charges,999999999,0.03087,92.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX POWD",0250,A9270,68308015230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,78.12 ,54.68 ,Aetna,"AETNA",35.15,45,percent of total billed charges,999999999,0.03087,92.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX POWD",0250,A9270,68308015260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,132.12 ,92.48 ,Aetna,"AETNA",59.45,45,percent of total billed charges,999999999,0.03087,92.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX POWD",0250,A9270,00574200815,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,108.27 ,75.79 ,Aetna,"AETNA",48.72,45,percent of total billed charges,999999999,0.03087,92.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EMTRICITABINE-TENOFOVIR DF 200-300 MG PO TABS",0250,A9270,42385095330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBOPLATIN 50 MG/5ML IV SOLN",0250,J9045,61703033918,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,74.58 ,52.21 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,52.206,fee schedule,""
"CARBOPLATIN 50 MG/5ML IV SOLN",0250,J9045,16729029531,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,42.14 ,29.50 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,52.206,fee schedule,""
"CARBOPLATIN 150 MG/15ML IV SOLN",0250,J9045,00703424601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,70.00 ,49.00 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,49,fee schedule,""
"CARBOPLATIN 150 MG/15ML IV SOLN",0250,J9045,71288010015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,62.06 ,43.44 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,49,fee schedule,""
"CARBOPLATIN 450 MG/45ML IV SOLN",0250,J9045,61703033950,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,262.98 ,184.09 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,372.519,fee schedule,""
"CARBOPLATIN 450 MG/45ML IV SOLN",0250,J9045,00703424801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,159.03 ,111.32 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,372.519,fee schedule,""
"CARBOPLATIN 450 MG/45ML IV SOLN",0250,J9045,63323017245,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,532.17 ,372.52 ,Aetna,"AETNA",7.11,191,fee schedule,999999999,2.41,372.519,fee schedule,""
"DULOXETINE HCL 20 MG PO CPEP",0250,A9270,00904704304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.90 ,4.83 ,Aetna,"AETNA",3.11,45,percent of total billed charges,999999999,0.03087,4.83,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DULOXETINE HCL 30 MG PO CPEP",0250,A9270,57237001890,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DULOXETINE HCL 60 MG PO CPEP",0250,A9270,00904704561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ADENOSINE 12 MG/4ML IV SOLN",0250,J0153,63323065104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,30.52 ,21.36 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,21.364,fee schedule,""
"CEFDINIR 250 MG/5ML PO SUSR",0250,A9270,99999032799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFDINIR 250 MG/5ML PO SUSR",0250,A9270,67877054898,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUMAZENIL 0.5 MG/5ML IV SOLN",0250,,63323042405,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,21.32 ,14.92 ,Aetna,"AETNA",9.59,45,percent of total billed charges,999999999,6.396,14.924,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IRON DEXTRAN 50 MG/ML INJ SOLN",0250,J1750,00023608210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,49.57 ,34.70 ,Aetna,"AETNA",33.06,191,fee schedule,999999999,14.163,34.699,fee schedule,""
"IRON DEXTRAN 50 MG/ML INJ SOLN",0250,J1750,00023608201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,47.21 ,33.05 ,Aetna,"AETNA",33.06,191,fee schedule,999999999,14.163,34.699,fee schedule,""
"TOBRAMYCIN SULFATE 80 MG/2ML INJ SOLN",0250,J3260,67457047322,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,5.89 ,4.12 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,1.767,4.8705,fee schedule,""
"TOBRAMYCIN SULFATE 80 MG/2ML INJ SOLN",0250,J3260,67457047300,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,5.89 ,4.12 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,1.767,4.8705,fee schedule,""
"LANTHANUM CARBONATE 500 MG PO CHEW",0250,A9270,69097093498,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.74 ,9.62 ,Aetna,"AETNA",6.18,45,percent of total billed charges,999999999,0.03087,9.618,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOFLURANE INH SOLN",0250,,10019036040,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,50.40 ,35.28 ,Aetna,"AETNA",22.68,45,percent of total billed charges,999999999,15.12,35.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NATALIZUMAB 300 MG/15ML IV CONC",0250,J2323,64406000801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,24628.05 ,17239.64 ,Aetna,"AETNA",46.28,191,fee schedule,999999999,24.03,17239.635,fee schedule,""
"ISONIAZID 100 MG/ML INJ SOLN",0250,,00781305670,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,480.05 ,336.04 ,Aetna,"AETNA",216.02,45,percent of total billed charges,999999999,144.015,336.035,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISONIAZID 300 MG PO TABS",0250,A9270,00555007102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN",0250,,00409434673,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,43.82 ,30.67 ,Aetna,"AETNA",19.72,45,percent of total billed charges,999999999,13.146,30.674,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOCAPROIC ACID 250 MG/ML IV SOLN",0250,,00409434616,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,43.82 ,30.67 ,Aetna,"AETNA",19.72,45,percent of total billed charges,999999999,13.146,30.674,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOPROTERENOL HCL 0.2 MG/ML INJ SOLN",0250,,00548950100,RC,,NDC,FACILITY,OUTPATIENT,0.1,ML,,27.65 ,19.36 ,Aetna,"AETNA",12.44,45,percent of total billed charges,999999999,8.295,19.355,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MESALAMINE 1000 MG PR SUPP",0250,A9270,31722000530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOFARABINE 1 MG/ML IV SOLN",0250,J9027,00955174601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3407.16 ,2385.01 ,Aetna,"AETNA",34.46,191,fee schedule,999999999,19.57,2385.012,fee schedule,""
"HYALURONIDASE OVINE 200 UNIT/ML INJ SOLN",0250,J3471,24208000202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,139.81 ,97.87 ,Aetna,"AETNA",1.15,191,fee schedule,999999999,0.49,97.867,fee schedule,""
"PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR",0250,J9264,68817013450,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,4621.68 ,3235.18 ,Aetna,"AETNA",26.19,191,fee schedule,999999999,12.06,3235.176,fee schedule,""
"ISOSORBIDE DINITRATE 10 MG PO TABS",0250,A9270,00904661961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE DINITRATE 20 MG PO TABS",0250,A9270,00904662061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE DINITRATE 30 MG PO TABS",0250,A9270,49884000901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE DINITRATE 5 MG PO TABS",0250,A9270,50268044711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ISOSORBIDE DINITRATE 5 MG PO TABS",0250,A9270,50268044715,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUTICASONE PROPIONATE HFA 44 MCG/ACT INH AERO",0250,A9270,66993007896,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10.6,GR,,746.41 ,522.49 ,Aetna,"AETNA",335.88,45,percent of total billed charges,999999999,0.03087,522.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUTICASONE PROPIONATE HFA 110 MCG/ACT INH AERO",0250,A9270,66993007996,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12,GR,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,0.03087,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOPHYLLINE 25 MG/ML IV SOLN",0250,J0280,00409592101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,80.58 ,56.41 ,Aetna,"AETNA",16.88,191,fee schedule,999999999,4.51,56.406,fee schedule,""
"AMINOPHYLLINE 25 MG/ML IV SOLN",0250,J0280,00409592116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,74.64 ,52.25 ,Aetna,"AETNA",16.88,191,fee schedule,999999999,4.51,56.406,fee schedule,""
"MICAFUNGIN SODIUM 50 MG IV SOLR",0250,J2248,00469325010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,522.36 ,365.65 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.75,365.652,fee schedule,""
"ENTECAVIR 0.5 MG PO TABS",0250,A9270,31722083330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.40 ,4.48 ,Aetna,"AETNA",2.88,45,percent of total billed charges,999999999,0.03087,4.48,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESOMEPRAZOLE SODIUM 40 MG IV SOLR",0250,,16729025269,RC,,NDC,FACILITY,OUTPATIENT,0.5,UN  ,,13.46 ,9.42 ,Aetna,"AETNA",6.06,45,percent of total billed charges,999999999,4.038,9.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESOMEPRAZOLE SODIUM 40 MG IV SOLR",0250,,16729025266,RC,,NDC,FACILITY,OUTPATIENT,0.5,UN  ,,13.46 ,9.42 ,Aetna,"AETNA",6.06,45,percent of total billed charges,999999999,4.038,9.422,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM IODIDE (ANTIDOTE) 65 MG/ML PO SOLN",0250,A9270,00178031430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,112.50 ,78.75 ,Aetna,"AETNA",50.63,45,percent of total billed charges,999999999,0.03087,78.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 12 MCG/HR TD PT72",0250,A9270,00378911998,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,69.72 ,48.80 ,Aetna,"AETNA",31.37,45,percent of total billed charges,999999999,0.03087,48.804,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FENTANYL 12 MCG/HR TD PT72",0250,A9270,00378911916,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,64.06 ,44.84 ,Aetna,"AETNA",28.83,45,percent of total billed charges,999999999,0.03087,48.804,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOCARNITINE 1 GM/10ML PO SOLN",0250,A9270,70954013910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.16 ,3.61 ,Aetna,"AETNA",2.32,45,percent of total billed charges,999999999,0.03087,3.612,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN K1 1 MG/0.5ML INJ SOLN",0250,J3430,00409915701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,23.33 ,16.33 ,Aetna,"AETNA",5.35,191,fee schedule,999999999,2.87,93.583,fee schedule,""
"VITAMIN K1 1 MG/0.5ML INJ SOLN",0250,J3430,76329124001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,133.69 ,93.58 ,Aetna,"AETNA",5.35,191,fee schedule,999999999,2.87,93.583,fee schedule,""
"VITAMIN K1 1 MG/0.5ML INJ SOLN",0250,J3430,69097070930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,32.59 ,22.81 ,Aetna,"AETNA",5.35,191,fee schedule,999999999,2.87,93.583,fee schedule,""
"VITAMIN K1 1 MG/0.5ML INJ SOLN",0250,J3430,69097070996,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,32.59 ,22.81 ,Aetna,"AETNA",5.35,191,fee schedule,999999999,2.87,93.583,fee schedule,""
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP",0250,90715,49281040020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,61.95 ,43.37 ,Aetna,"AETNA",27.88,45,percent of total billed charges,999999999,15.4875,43.365,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP",0250,90715,49281040089,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,61.95 ,43.37 ,Aetna,"AETNA",27.88,45,percent of total billed charges,999999999,15.4875,43.365,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TIGECYCLINE 50 MG IV SOLR",0250,J3243,70121164701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,94.02 ,65.81 ,Aetna,"AETNA",1.28,191,fee schedule,999999999,0.62,65.814,fee schedule,""
"TIGECYCLINE 50 MG IV SOLR",0250,J3243,70121164707,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,94.02 ,65.81 ,Aetna,"AETNA",1.28,191,fee schedule,999999999,0.62,65.814,fee schedule,""
"VINORELBINE TARTRATE 50 MG/5ML IV SOLN",0250,J9390,64370053202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,525.30 ,367.71 ,Aetna,"AETNA",16.24,191,fee schedule,999999999,7.416,367.71,fee schedule,""
"VINORELBINE TARTRATE 50 MG/5ML IV SOLN",0250,J9390,25021020405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,271.50 ,190.05 ,Aetna,"AETNA",16.24,191,fee schedule,999999999,7.416,367.71,fee schedule,""
"PALIVIZUMAB 100 MG/ML IM SOLN",0250,90378,60574411301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,9223.95 ,6456.77 ,Aetna,"AETNA",4150.78,45,percent of total billed charges,999999999,2305.9875,8219.664,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PALIVIZUMAB 100 MG/ML IM SOLN",0250,90378,66658023101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,10274.58 ,7192.21 ,Aetna,"AETNA",4623.56,45,percent of total billed charges,999999999,2305.9875,8219.664,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM TETRADECYL SULFATE 1 % IV SOLN",0250,,67457016202,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,468.80 ,328.16 ,Aetna,"AETNA",210.96,45,percent of total billed charges,999999999,140.64,328.16,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM TETRADECYL SULFATE 3 % IV SOLN",0250,,67457016302,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,435.34 ,304.74 ,Aetna,"AETNA",195.90,45,percent of total billed charges,999999999,130.602,304.738,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE 5 % EX OINT",0250,,70752011303,RC,,NDC,FACILITY,OUTPATIENT,35.44,GR,,47.14 ,33.00 ,Aetna,"AETNA",21.21,45,percent of total billed charges,999999999,14.142,32.998,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SILDENAFIL CITRATE 20 MG PO TABS",0250,A9270,00904667106,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 40 MG PO TBSO",0250,A9270,00054453825,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREGABALIN 25 MG PO CAPS",0250,A9270,00904699161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREGABALIN 75 MG PO CAPS",0250,A9270,00904700061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREGABALIN 100 MG PO CAPS",0250,A9270,00904700161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREGABALIN 150 MG PO CAPS",0250,A9270,00904700261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 10 MG/ML INJ SOLN",0250,,55150043801,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,81.60 ,57.12 ,Aetna,"AETNA",36.72,45,percent of total billed charges,999999999,24.48,61.74,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 10 MG/ML INJ SOLN",0250,,55150043810,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,88.20 ,61.74 ,Aetna,"AETNA",39.69,45,percent of total billed charges,999999999,24.48,61.74,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 100 MG/ML INJ SOLN",0250,,00143950901,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,70.92 ,49.64 ,Aetna,"AETNA",31.91,45,percent of total billed charges,999999999,21,49.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 100 MG/ML INJ SOLN",0250,,00143950910,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,70.92 ,49.64 ,Aetna,"AETNA",31.91,45,percent of total billed charges,999999999,21,49.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 100 MG/ML INJ SOLN",0250,,55150044001,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KETAMINE HCL 100 MG/ML INJ SOLN",0250,,55150044010,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROXYPROPYL-BETA-CYCLODEXT POWD",0250,,51927308100,RC,,NDC,FACILITY,OUTPATIENT,1,GR,,30.80 ,21.56 ,Aetna,"AETNA",13.86,45,percent of total billed charges,999999999,9.24,21.56,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 10 MG PO TABS",0250,A9270,50268003711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 10 MG PO TABS",0250,A9270,50268003715,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE POWD",0250,,38779064008,RC,,NDC,FACILITY,OUTPATIENT,500,GR,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 100 MG PO TABS",0250,A9270,50268004115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTOSE POWD",0250,A9270,00395150101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,247.88 ,173.52 ,Aetna,"AETNA",111.55,45,percent of total billed charges,999999999,0.03087,173.516,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 25 MG PO TABS",0250,A9270,60687043301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 25 MG PO TABS",0250,A9270,60687043311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NELARABINE 5 MG/ML IV SOLN",0250,J9261,00078068361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",194.69,191,fee schedule,999999999,110.58,2100,fee schedule,""
"LOPINAVIR-RITONAVIR 200-50 MG PO TABS",0250,A9270,00074679922,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,116.49 ,81.54 ,Aetna,"AETNA",52.42,45,percent of total billed charges,999999999,0.03087,81.543,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 50 MG PO TABS",0250,A9270,60687044401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 50 MG PO TABS",0250,A9270,60687044411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IODINE RESUBLIMED GRAN",0250,,00075535602,RC,,NDC,FACILITY,OUTPATIENT,100,GR,,1515.00 ,1060.50 ,Aetna,"AETNA",681.75,45,percent of total billed charges,999999999,454.5,1060.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYALURONIDASE HUMAN 150 UNIT/ML INJ SOLN",0250,J3473,18657011704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,223.49 ,156.44 ,Aetna,"AETNA",0.69,191,fee schedule,999999999,0.36,156.443,fee schedule,""
"DIGOXIN 0.05 MG/ML PO SOLN",0250,A9270,00054005746,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,28.19 ,19.73 ,Aetna,"AETNA",12.69,45,percent of total billed charges,999999999,0.03087,19.733,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 75 MG PO TABS",0250,A9270,50268004011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMITRIPTYLINE HCL 75 MG PO TABS",0250,A9270,50268004015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ABATACEPT 250 MG IV SOLR",0250,J0129,00003218713,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,4177.50 ,2924.25 ,Aetna,"AETNA",81.82,191,fee schedule,999999999,42.7,2924.25,fee schedule,""
"LIDOCAINE HCL 4 % MT SOLN",0250,,76329630005,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,174.19 ,121.93 ,Aetna,"AETNA",78.39,45,percent of total billed charges,999999999,52.257,121.933,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARIPIPRAZOLE 2 MG PO TABS",0250,A9270,65162089603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEUCOVORIN CALCIUM 100 MG INJ SOLR",0250,J0640,00703514001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,232.92 ,163.04 ,Aetna,"AETNA",9.82,191,fee schedule,999999999,4.02,163.044,fee schedule,""
"LEUCOVORIN CALCIUM 350 MG INJ SOLR",0250,J0640,67457053035,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,105.84 ,74.09 ,Aetna,"AETNA",9.82,191,fee schedule,999999999,4.02,74.088,fee schedule,""
"SULFACETAMIDE-PREDNISOLONE 10-0.23 % OP SOLN",0250,A9270,24208031705,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,77.22 ,54.05 ,Aetna,"AETNA",34.75,45,percent of total billed charges,999999999,0.03087,54.054,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUETIAPINE FUMARATE 50 MG PO TABS",0250,A9270,00904663961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR",0250,J7187,63833061502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,2000.00 ,1400.00 ,Aetna,"AETNA",2.67,191,fee schedule,999999999,1.3,1400,fee schedule,""
"ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR",0250,J7187,63833061602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,4290.00 ,3003.00 ,Aetna,"AETNA",2.67,191,fee schedule,999999999,1.3,3003,fee schedule,""
"LEUCOVORIN CALCIUM 25 MG PO TABS",0250,A9270,00904670310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.94 ,6.96 ,Aetna,"AETNA",4.47,45,percent of total billed charges,999999999,0.03087,6.958,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEUCOVORIN CALCIUM 5 MG PO TABS",0250,A9270,00054849619,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.86 ,7.60 ,Aetna,"AETNA",4.89,45,percent of total billed charges,999999999,0.03087,7.602,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RANOLAZINE ER 500 MG PO TB12",0250,A9270,60687054911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.67 ,6.07 ,Aetna,"AETNA",3.90,45,percent of total billed charges,999999999,0.03087,6.069,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RANOLAZINE ER 500 MG PO TB12",0250,A9270,60687054921,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.67 ,6.07 ,Aetna,"AETNA",3.90,45,percent of total billed charges,999999999,0.03087,6.069,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANIDULAFUNGIN 50 MG IV SOLR",0250,J0348,00049011428,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,244.56 ,171.19 ,Aetna,"AETNA",0.88,191,fee schedule,999999999,0.46,171.192,fee schedule,""
"SELEGILINE 6 MG/24HR TD PT24",0250,A9270,49502090030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,380.42 ,266.29 ,Aetna,"AETNA",171.19,45,percent of total billed charges,999999999,0.03087,266.294,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 25 MCG PO TABS",0250,A9270,60687045301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 25 MCG PO TABS",0250,A9270,60687045311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 50 MCG PO TABS",0250,A9270,00904695061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 75 MCG PO TABS",0250,A9270,00904695161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 100 MCG PO TABS",0250,A9270,00904695361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.20 ,4.34 ,Aetna,"AETNA",2.79,45,percent of total billed charges,999999999,0.03087,4.34,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 125 MCG PO TABS",0250,A9270,00904695561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 150 MCG PO TABS",0250,A9270,00904695661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 200 MCG PO TABS",0250,A9270,60687055201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 200 MCG PO TABS",0250,A9270,60687055211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVOTHYROXINE SODIUM 300 MCG PO TABS",0250,A9270,68180097601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALGLUCOSIDASE ALFA 50 MG IV SOLR",0250,J0221,58468016001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",376.84,191,fee schedule,999999999,188.31,2100,fee schedule,""
"CIPROFLOXACIN 250 MG/5ML (5%) PO SUSR",0250,A9270,50419077701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,36.42 ,25.49 ,Aetna,"AETNA",16.39,45,percent of total billed charges,999999999,0.03087,25.494,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DECITABINE 50 MG IV SOLR",0250,J0894,55111055610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,325.14 ,227.60 ,Aetna,"AETNA",3.13,191,fee schedule,999999999,0.777,227.598,fee schedule,""
"DECITABINE 50 MG IV SOLR",0250,J0893,47335036141,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,283.02 ,198.11 ,Aetna,"AETNA",4.58,191,fee schedule,999999999,0.777,227.598,fee schedule,""
"LIDOCAINE HCL 4 % EX SOLN",0250,,00527600480,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,151.80 ,106.26 ,Aetna,"AETNA",68.31,45,percent of total billed charges,999999999,45.54,106.26,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN",0250,,63323048527,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,11.76 ,8.23 ,Aetna,"AETNA",5.29,45,percent of total billed charges,999999999,2.4,15.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN",0250,,63323048501,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,11.76 ,8.23 ,Aetna,"AETNA",5.29,45,percent of total billed charges,999999999,2.4,15.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN",0250,,70756064625,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,15.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 1 % INJ SOLN",0250,,63323020110,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,22.12 ,15.48 ,Aetna,"AETNA",9.95,45,percent of total billed charges,999999999,2.4,15.484,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN",0250,,63323048617,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,13.37 ,9.36 ,Aetna,"AETNA",6.02,45,percent of total billed charges,999999999,3.36,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN",0250,,63323048627,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,11.20 ,7.84 ,Aetna,"AETNA",5.04,45,percent of total billed charges,999999999,3.36,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN",0250,,63323048602,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,11.20 ,7.84 ,Aetna,"AETNA",5.04,45,percent of total billed charges,999999999,3.36,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL 2 % INJ SOLN",0250,,63323020202,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,21.49 ,15.04 ,Aetna,"AETNA",9.67,45,percent of total billed charges,999999999,3.36,15.043,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RASAGILINE MESYLATE 1 MG PO TABS",0250,A9270,67877026030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.38 ,4.47 ,Aetna,"AETNA",2.87,45,percent of total billed charges,999999999,0.03087,4.466,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAKINS (1/4 STRENGTH) 0.125 % EX SOLN",0250,,00436067216,RC,,NDC,FACILITY,OUTPATIENT,473,ML,,107.84 ,75.49 ,Aetna,"AETNA",48.53,45,percent of total billed charges,999999999,21,75.488,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DAKINS (1/4 STRENGTH) 0.125 % EX SOLN",0250,,99999576699,RC,,NDC,FACILITY,OUTPATIENT,473,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,75.488,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RASBURICASE 7.5 MG IV SOLR",0250,J2783,00024515175,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,16056.45 ,11239.52 ,Aetna,"AETNA",701.89,191,fee schedule,999999999,332.08,11239.515,fee schedule,""
"IDURSULFASE 6 MG/3ML IV SOLN",0250,J1743,54092070001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9407.49 ,6585.24 ,Aetna,"AETNA",1036.92,191,fee schedule,999999999,542.61,6585.243,fee schedule,""
"AMOXICILLIN 250 MG PO CAPS",0250,A9270,00781202001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIOTHYRONINE SODIUM 25 MCG PO TABS",0250,A9270,62756059088,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXMETHYLPHENIDATE HCL ER 15 MG PO CP24",0250,A9270,70010000601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.58 ,6.71 ,Aetna,"AETNA",4.31,45,percent of total billed charges,999999999,2.395,6.706,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN 500 MG PO CAPS",0250,A9270,00781261301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVETIRACETAM 500 MG/5ML IV SOLN",0250,J1953,00409188602,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.00 ,9.80 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.063,9.8,fee schedule,""
"LISINOPRIL 20 MG PO TABS",0250,A9270,00904679961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOBUTAMINE HCL 250 MG/20ML IV SOLN",0250,J1250,00409234402,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,41.16 ,28.81 ,Aetna,"AETNA",17.69,191,fee schedule,999999999,6.54,28.812,fee schedule,""
"AMOXICILLIN 125 MG/5ML PO SUSR",0250,A9270,00781603955,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LITHIUM CARBONATE 300 MG PO TABS",0250,A9270,00054852825,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POSACONAZOLE 40 MG/ML PO SUSP",0250,A9270,00085132801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,95.74 ,67.02 ,Aetna,"AETNA",43.08,45,percent of total billed charges,999999999,0.03087,67.018,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEG-KCL-NACL-NASULF-NA ASC-C 100 G PO SOLR",0250,A9270,00093356026,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,187.14 ,131.00 ,Aetna,"AETNA",84.21,45,percent of total billed charges,999999999,0.03087,130.998,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAFFEINE CITRATE 20 MG/ML PO SOLN",0250,A9270,51754050103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAFFEINE CITRATE 60 MG/3ML IV SOLN",0250,J0706,51754050001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,25.83 ,18.08 ,Aetna,"AETNA",3.92,191,fee schedule,999999999,1.71,18.081,fee schedule,""
"AMOXICILLIN 250 MG/5ML PO SUSR",0250,A9270,00781604146,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN 250 MG/5ML PO SUSR",0250,A9270,99999002199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 25 MG PO TABS",0250,A9270,00006022131,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,96.04 ,67.23 ,Aetna,"AETNA",43.22,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 50 MG PO TABS",0250,A9270,00006011228,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,96.04 ,67.23 ,Aetna,"AETNA",43.22,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 50 MG PO TABS",0250,A9270,00006011201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 100 MG PO TABS",0250,A9270,00006027728,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,96.04 ,67.23 ,Aetna,"AETNA",43.22,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 100 MG PO TABS",0250,A9270,00006027754,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,96.04 ,67.23 ,Aetna,"AETNA",43.22,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SITAGLIPTIN PHOSPHATE 100 MG PO TABS",0250,A9270,00006027701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,67.228,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOPERAMIDE HCL 2 MG PO CAPS",0250,A9270,60687022901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOPERAMIDE HCL 2 MG PO CAPS",0250,A9270,60687022911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MICAFUNGIN SODIUM 100 MG IV SOLR",0250,J2248,71288002910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,135.47 ,94.83 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.75,94.829,fee schedule,""
"MICAFUNGIN SODIUM 100 MG IV SOLR",0250,J2248,71288002911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,135.47 ,94.83 ,Aetna,"AETNA",1.34,191,fee schedule,999999999,0.75,94.829,fee schedule,""
"METOCLOPRAMIDE HCL 5 MG/5ML PO SOLN",0250,A9270,62559019016,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,73.79 ,51.65 ,Aetna,"AETNA",33.21,45,percent of total billed charges,999999999,0.03087,51.653,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 2 MG/ML PO CONC",0250,A9270,00121077001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 2 MG/ML PO CONC",0250,A9270,99999008299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 0.5 MG PO TABS",0250,A9270,00904600761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 1 MG PO TABS",0250,A9270,00904600861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LORAZEPAM 2 MG PO TABS",0250,A9270,64125090601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOXAPINE SUCCINATE 5 MG PO CAPS",0250,A9270,00591036901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PALIPERIDONE ER 6 MG PO TB24",0250,A9270,47335076683,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.23 ,6.46 ,Aetna,"AETNA",4.15,45,percent of total billed charges,999999999,2.769,6.461,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LOXAPINE SUCCINATE 50 MG PO CAPS",0250,A9270,00591037201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.33 ,3.73 ,Aetna,"AETNA",2.40,45,percent of total billed charges,999999999,0.03087,3.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MESALAMINE 1.2 G PO TBEC",0250,A9270,00527301248,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,44.03 ,30.82 ,Aetna,"AETNA",19.81,45,percent of total billed charges,999999999,0.03087,30.821,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZACITIDINE 100 MG INJ SUSR",0250,J9025,59572010201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2500.00 ,1750.00 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.353,1750,fee schedule,""
"AZACITIDINE 100 MG INJ SUSR",0250,J9025,00781325394,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,273.72 ,191.60 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.353,1750,fee schedule,""
"AMPICILLIN SODIUM 1 G INJ SOLR",0250,J0290,55150011310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,8.54 ,5.98 ,Aetna,"AETNA",1.91,191,fee schedule,999999999,0.76,5.978,fee schedule,""
"MAGNESIUM CITRATE PO SOLN",0250,A9270,00904741844,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ML,,24.86 ,17.40 ,Aetna,"AETNA",11.19,45,percent of total billed charges,999999999,0.03087,17.402,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMPICILLIN SODIUM 2 G INJ SOLR",0250,J0290,55150011420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,15.18 ,10.63 ,Aetna,"AETNA",1.91,191,fee schedule,999999999,0.76,10.626,fee schedule,""
"MAGNESIUM SULFATE 50 % INJ SOLN",0250,J3475,63323064220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,5.6,fee schedule,""
"MAGNESIUM SULFATE 50 % INJ SOLN",0250,J3475,63323006403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,8.00 ,5.60 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,5.6,fee schedule,""
"MAGNESIUM SULFATE 50 % INJ SOLN",0250,J3475,63323064201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.691,5.6,fee schedule,""
"AMPICILLIN SODIUM 500 MG INJ SOLR",0250,J0290,00781340795,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,5.93 ,4.15 ,Aetna,"AETNA",1.91,191,fee schedule,999999999,0.76,4.151,fee schedule,""
"AMPICILLIN SODIUM 500 MG INJ SOLR",0250,J0290,00781340778,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,5.85 ,4.10 ,Aetna,"AETNA",1.91,191,fee schedule,999999999,0.76,4.151,fee schedule,""
"MANNITOL 20 % IV SOLN",0250,,00990771503,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MANNITOL 20 % IV SOLN",0250,,00990771513,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MANNITOL 25 % IV SOLN",0250,J2150,00409403101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,13.30 ,9.31 ,Aetna,"AETNA",8.63,191,fee schedule,999999999,2.595,9.31,fee schedule,""
"MANNITOL 25 % IV SOLN",0250,J2150,00409403116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,11.20 ,7.84 ,Aetna,"AETNA",8.63,191,fee schedule,999999999,2.595,9.31,fee schedule,""
"MEDROXYPROGESTERONE ACETATE 10 MG PO TABS",0250,A9270,00555077902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS",0250,A9270,00555087202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS",0250,A9270,59762374001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEDROXYPROGESTERONE ACETATE 5 MG PO TABS",0250,A9270,59762374101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEGESTROL ACETATE 20 MG PO TABS",0250,,00555060602,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MEPERIDINE HCL 100 MG/ML INJ SOLN",0250,J2175,00641605401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,8.00 ,5.60 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.4,13.179,fee schedule,""
"MEPERIDINE HCL 100 MG/ML INJ SOLN",0250,J2175,00641605425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,16.65 ,11.66 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.4,13.179,fee schedule,""
"MEPERIDINE HCL 25 MG/ML INJ SOLN",0250,J2175,00641605201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,7.03 ,4.92 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.109,13.179,fee schedule,""
"MEPERIDINE HCL 25 MG/ML INJ SOLN",0250,J2175,00641605225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,14.58 ,10.21 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.109,13.179,fee schedule,""
"MEPERIDINE HCL 50 MG/ML INJ SOLN",0250,J2175,00641605301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,7.25 ,5.08 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.175,13.179,fee schedule,""
"MEPERIDINE HCL 50 MG/ML INJ SOLN",0250,J2175,00641605325,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,15.19 ,10.63 ,Aetna,"AETNA",13.18,191,fee schedule,999999999,2.175,13.179,fee schedule,""
"METHADONE HCL 5 MG/5ML PO SOLN",0250,A9270,99999008099,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,11.03 ,7.72 ,Aetna,"AETNA",4.96,45,percent of total billed charges,999999999,0.03087,7.721,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 5 MG/5ML PO SOLN",0250,A9270,00054355563,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,7.721,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 10 MG PO TABS",0250,A9270,00406577162,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 10 MG PO TABS",0250,A9270,00406577123,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 5 MG PO TABS",0250,A9270,00406575523,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHADONE HCL 5 MG PO TABS",0250,A9270,00054855324,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHAZOLAMIDE 50 MG PO TABS",0250,A9270,00781107101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,53.63 ,37.54 ,Aetna,"AETNA",24.13,45,percent of total billed charges,999999999,0.03087,37.541,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHOCARBAMOL 500 MG PO TABS",0250,A9270,00904705761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHOCARBAMOL 750 MG PO TABS",0250,A9270,00904705861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHOTREXATE SODIUM 1 G INJ SOLR",0250,J9260,00143983001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,355.02 ,248.51 ,Aetna,"AETNA",4.91,191,fee schedule,999999999,2.33,248.514,fee schedule,""
"METHYLDOPA 250 MG PO TABS",0250,A9270,00378061101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLDOPA 500 MG PO TABS",0250,A9270,00378042101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLPHENIDATE HCL 5 MG PO TABS",0250,A9270,10702010001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHYLPREDNISOLONE 16 MG PO TABS",0250,J7509,59762005001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.227,3.5,fee schedule,""
"METHYLPREDNISOLONE 16 MG PO TABS",0250,J7509,68382091818,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.227,3.5,fee schedule,""
"METHYLPREDNISOLONE 4 MG PO TABS",0250,J7509,00781502201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,4,ME,,8.01 ,5.61 ,Aetna,"AETNA",0.48,191,fee schedule,999999999,0.227,5.607,fee schedule,""
"METHYLPREDNISOLONE ACETATE 40 MG/ML INJ SUSP",0250,J1010,00009307301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,6.09 ,4.26 ,Aetna,"AETNA",0.25,191,fee schedule,999999999,0.15,6.153,fee schedule,""
"METHYLPREDNISOLONE ACETATE 40 MG/ML INJ SUSP",0250,J1010,00009307303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,8.79 ,6.15 ,Aetna,"AETNA",0.25,191,fee schedule,999999999,0.15,6.153,fee schedule,""
"METHYLPREDNISOLONE ACETATE 80 MG/ML INJ SUSP",0250,J1010,00009347501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,37.38 ,26.17 ,Aetna,"AETNA",0.25,191,fee schedule,999999999,0.15,38.101,fee schedule,""
"METHYLPREDNISOLONE ACETATE 80 MG/ML INJ SUSP",0250,J1010,00009347503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,54.43 ,38.10 ,Aetna,"AETNA",0.25,191,fee schedule,999999999,0.15,38.101,fee schedule,""
"BLINATUMOMAB 7-DAY INFUSION IN CADD PUMP",0250,,99999026699,RC,,NDC,FACILITY,OUTPATIENT,110,ML,,64153.32 ,44907.32 ,Aetna,"AETNA",28868.99,45,percent of total billed charges,999999999,6541,44907.324,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLINATUMOMAB 24-HOUR INFUSION IN CADD PUMP",0250,,99999028499,RC,,NDC,FACILITY,OUTPATIENT,270,ML,,8897.83 ,6228.48 ,Aetna,"AETNA",4004.02,45,percent of total billed charges,999999999,2669.349,6228.481,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLINATUMOMAB 48-HOUR INFUSION IN CADD PUMP",0250,,99999028599,RC,,NDC,FACILITY,OUTPATIENT,270,ML,,18329.52 ,12830.66 ,Aetna,"AETNA",8248.28,45,percent of total billed charges,999999999,5498.856,12830.664,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLINATUMOMAB WEIGHT-BASED 24-HOUR CADD PUMP INFUSION (PEDS ONC)",0250,,99999031299,RC,,NDC,FACILITY,OUTPATIENT,270,ML,,11122.26 ,7785.58 ,Aetna,"AETNA",5005.02,45,percent of total billed charges,999999999,3336.678,7785.582,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLINATUMOMAB WEIGHT-BASED 48-HOUR CADD PUMP INFUSION (PEDS ONC)",0250,,99999031399,RC,,NDC,FACILITY,OUTPATIENT,270,ML,,11122.29 ,7785.60 ,Aetna,"AETNA",5005.03,45,percent of total billed charges,999999999,3336.687,7785.603,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRETINOIN ORAL SUSP",0250,,99999050499,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,1064.50 ,745.15 ,Aetna,"AETNA",479.03,45,percent of total billed charges,999999999,319.35,745.15,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CISPLATIN 1 MG/ML INTRAPERITONEAL SYRINGE (HIPEC)",0250,J9060,63323010365,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,390.00 ,273.00 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,273,fee schedule,""
"DOXORUBICIN 2 MG/ML INTRAPERITONEAL SYRINGE (HIPEC)",0250,J9000,00069303420,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,278.40 ,194.88 ,Aetna,"AETNA",6.97,191,fee schedule,999999999,2.43,194.88,fee schedule,""
"METOCLOPRAMIDE HCL 5 MG/ML INJ SOLN",0250,J2765,00409341401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.99,191,fee schedule,999999999,1.06,3.5,fee schedule,""
"METOCLOPRAMIDE HCL 10 MG PO TABS",0250,A9270,60687063101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOCLOPRAMIDE HCL 10 MG PO TABS",0250,A9270,60687063111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOCLOPRAMIDE HCL 5 MG PO TABS",0250,A9270,51079088601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.86 ,4.10 ,Aetna,"AETNA",2.64,45,percent of total billed charges,999999999,0.03087,4.102,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOCLOPRAMIDE HCL 5 MG PO TABS",0250,A9270,51079088620,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.86 ,4.10 ,Aetna,"AETNA",2.64,45,percent of total billed charges,999999999,0.03087,4.102,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL TARTRATE 100 MG PO TABS",0250,A9270,62332011431,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL TARTRATE 50 MG PO TABS",0250,A9270,51079080120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE 250 MG PO TABS",0250,A9270,00904715661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METRONIDAZOLE 500 MG PO TABS",0250,A9270,00904712661,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MICONAZOLE NITRATE 2 % EX CREA",0250,A9270,61269073556,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,15.09 ,10.56 ,Aetna,"AETNA",6.79,45,percent of total billed charges,999999999,0.03087,10.563,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MICONAZOLE NITRATE 2 % VA CREA",0250,A9270,51672203506,RC,HCPCS,NDC,FACILITY,OUTPATIENT,47,GR,,36.86 ,25.80 ,Aetna,"AETNA",16.59,45,percent of total billed charges,999999999,0.03087,25.802,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINERAL OIL PO OIL",0250,A9270,70000044801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOCYCLINE HCL 50 MG PO CAPS",0250,A9270,68382031601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOXIDIL 10 MG PO TABS",0250,A9270,68084020501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOXIDIL 10 MG PO TABS",0250,A9270,68084020511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOXIDIL 2.5 MG PO TABS",0250,A9270,68084020401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MINOXIDIL 2.5 MG PO TABS",0250,A9270,68084020411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 2 MG/ML INJ SOLN",0250,J2272,76045000401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,13.29 ,9.30 ,Aetna,"AETNA",13.90,191,fee schedule,999999999,3.3225,13.9048,fee schedule,""
"MORPHINE SULFATE 2 MG/ML INJ SOLN",0250,J2272,76045000411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,14.34 ,10.04 ,Aetna,"AETNA",13.90,191,fee schedule,999999999,3.3225,13.9048,fee schedule,""
"MORPHINE SULFATE 10 MG/5ML PO SOLN",0250,,00121090405,RC,,NDC,FACILITY,OUTPATIENT,1.25,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 10 MG/5ML PO SOLN",0250,,00121090494,RC,,NDC,FACILITY,OUTPATIENT,1.25,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 15 MG PO TABS",0250,A9270,00406511801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,4.158,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 15 MG PO TABS",0250,A9270,00406511862,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.94 ,4.16 ,Aetna,"AETNA",2.67,45,percent of total billed charges,999999999,0.03087,4.158,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MORPHINE SULFATE 30 MG PO TABS",0250,A9270,00054023625,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NADOLOL 20 MG PO TABS",0250,A9270,00904707007,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.39 ,10.77 ,Aetna,"AETNA",6.93,45,percent of total billed charges,999999999,0.03087,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAFCILLIN SODIUM 1 G INJ SOLR",0250,,55150012215,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,24.86 ,17.40 ,Aetna,"AETNA",11.19,45,percent of total billed charges,999999999,7.458,17.402,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAFCILLIN SODIUM 2 G INJ SOLR",0250,,25021014010,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,208.32 ,145.82 ,Aetna,"AETNA",93.74,45,percent of total billed charges,999999999,11.601,145.824,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAFCILLIN SODIUM 2 G INJ SOLR",0250,,55150012315,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,38.67 ,27.07 ,Aetna,"AETNA",17.40,45,percent of total billed charges,999999999,11.601,145.824,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NALOXONE HCL 0.4 MG/ML INJ SOLN",0250,J2310,00409121501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,18.90 ,13.23 ,Aetna,"AETNA",15.39,191,fee schedule,999999999,5.67,15.3946,fee schedule,""
"NALOXONE HCL 0.4 MG/ML INJ SOLN",0250,J2310,00409121521,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,18.90 ,13.23 ,Aetna,"AETNA",15.39,191,fee schedule,999999999,5.67,15.3946,fee schedule,""
"NAPROXEN 250 MG PO TABS",0250,A9270,68462018801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAPROXEN 250 MG PO TABS",0250,A9270,50268059411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAPROXEN 250 MG PO TABS",0250,A9270,50268059415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAPROXEN 375 MG PO TABS",0250,A9270,70010013801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NAPROXEN 500 MG PO TABS",0250,A9270,63739040310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NEOMYCIN SULFATE 500 MG PO TABS",0250,A9270,39822031005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIACIN 100 MG PO TABS",0250,A9270,80681005700,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIACIN 250 MG PO TABS",0250,A9270,54629071001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIACIN 500 MG PO TABS",0250,A9270,00904227260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NIFEDIPINE 10 MG PO CAPS",0250,A9270,23155019401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 5 MG/ML IV SOLN",0250,J2305,00517481025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,70.00 ,49.00 ,Aetna,"AETNA",2.75,191,fee schedule,999999999,1.286,49,fee schedule,""
"NITROGLYCERIN 0.4 MG SL SUBL",0250,A9270,00071041813A,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 0.4 MG SL SUBL",0250,A9270,59762330403,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 2 % TD OINT",0250,A9270,00281032608,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,14.36 ,10.05 ,Aetna,"AETNA",6.46,45,percent of total billed charges,999999999,0.03087,133.182,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NITROGLYCERIN 2 % TD OINT",0250,A9270,00281032630,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,190.26 ,133.18 ,Aetna,"AETNA",85.62,45,percent of total billed charges,999999999,0.03087,133.182,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORTRIPTYLINE HCL 10 MG PO CAPS",0250,A9270,50268060311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORTRIPTYLINE HCL 10 MG PO CAPS",0250,A9270,50268060315,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORTRIPTYLINE HCL 25 MG PO CAPS",0250,A9270,60687029301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NORTRIPTYLINE HCL 25 MG PO CAPS",0250,A9270,60687029311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX CREA",0250,A9270,45802005935,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,27.83 ,19.48 ,Aetna,"AETNA",12.52,45,percent of total billed charges,999999999,0.03087,51.03,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX CREA",0250,A9270,51672128902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,72.90 ,51.03 ,Aetna,"AETNA",32.81,45,percent of total billed charges,999999999,0.03087,51.03,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/GM EX OINT",0250,A9270,00713068615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,22.79 ,15.95 ,Aetna,"AETNA",10.26,45,percent of total billed charges,999999999,0.03087,15.953,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/ML MT SUSP",0250,A9270,00904727670,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.16 ,3.61 ,Aetna,"AETNA",2.32,45,percent of total billed charges,999999999,0.03087,3.612,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN 100000 UNIT/ML MT SUSP",0250,A9270,00904727641,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.16 ,3.61 ,Aetna,"AETNA",2.32,45,percent of total billed charges,999999999,0.03087,3.612,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA",0250,A9270,51672126301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,116.91 ,81.84 ,Aetna,"AETNA",52.61,45,percent of total billed charges,999999999,0.03087,81.837,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT",0250,A9270,62332058515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,28.56 ,19.99 ,Aetna,"AETNA",12.85,45,percent of total billed charges,999999999,0.03087,19.992,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ORA-PLUS PO LIQD",0250,A9270,00395009116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,85.14 ,59.60 ,Aetna,"AETNA",38.31,45,percent of total billed charges,999999999,0.03087,84,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ORA-PLUS PO LIQD",0250,A9270,51552112305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,120.00 ,84.00 ,Aetna,"AETNA",54.00,45,percent of total billed charges,999999999,0.03087,84,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ORA-SWEET PO SYRP",0250,A9270,00574030216,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,113.52 ,79.46 ,Aetna,"AETNA",51.08,45,percent of total billed charges,999999999,0.03087,79.464,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXAZEPAM 10 MG PO CAPS",0250,A9270,00228206710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.89 ,4.12 ,Aetna,"AETNA",2.65,45,percent of total billed charges,999999999,0.03087,4.123,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYBUTYNIN CHLORIDE 5 MG PO TABS",0250,A9270,00832003801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS",0250,A9270,00904709361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYMETAZOLINE HCL 0.05 % NA SOLN",0250,A9270,41100081123,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,54.29 ,38.00 ,Aetna,"AETNA",24.43,45,percent of total billed charges,999999999,0.03087,38.003,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYMETAZOLINE HCL 0.05 % NA SOLN",0250,A9270,00904676130,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,16.17 ,11.32 ,Aetna,"AETNA",7.28,45,percent of total billed charges,999999999,0.03087,38.003,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYTOCIN 10 UNIT/ML INJ SOLN",0250,J2590,63323001206,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",3.21,191,fee schedule,999999999,1.4,6.664,fee schedule,""
"OXYTOCIN 10 UNIT/ML INJ SOLN",0250,J2590,63323001203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,9.52 ,6.66 ,Aetna,"AETNA",3.21,191,fee schedule,999999999,1.4,6.664,fee schedule,""
"OXYTOCIN 10 UNIT/ML INJ SOLN",0250,J2590,63323001210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",3.21,191,fee schedule,999999999,1.4,6.664,fee schedule,""
"OYSTER SHELL CALCIUM 500 MG PO TABS",0250,A9270,00904188361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PANCURONIUM BROMIDE 1 MG/ML IV SOLN",0250,,00409464601,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,35.42 ,24.79 ,Aetna,"AETNA",15.94,45,percent of total billed charges,999999999,10.626,24.794,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PAPAVERINE HCL 30 MG/ML INJ SOLN",0250,J2440,14789012105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,ME,,93.85 ,65.70 ,Aetna,"AETNA",85.95,191,fee schedule,999999999,28.155,85.95,fee schedule,""
"PENICILLIN G POTASSIUM 20000000 UNITS INJ SOLR",0250,J2540,00049053028,RC,HCPCS,NDC,FACILITY,OUTPATIENT,600000,UN  ,,152.28 ,106.60 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.771,106.596,fee schedule,""
"PENICILLIN G POTASSIUM 5000000 UNITS INJ SOLR",0250,J2540,00049052084,RC,HCPCS,NDC,FACILITY,OUTPATIENT,600000,UN  ,,37.92 ,26.54 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.771,26.544,fee schedule,""
"PENICILLIN G POTASSIUM 5000000 UNITS INJ SOLR",0250,J2540,00049052083,RC,HCPCS,NDC,FACILITY,OUTPATIENT,600000,UN  ,,28.67 ,20.07 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.771,26.544,fee schedule,""
"PENICILLIN V POTASSIUM 125 MG/5ML PO SOLR",0250,A9270,00093412573,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR",0250,A9270,00093412774,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENICILLIN V POTASSIUM 250 MG PO TABS",0250,A9270,65862017501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENICILLIN V POTASSIUM 500 MG PO TABS",0250,A9270,65862017601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PENTOBARBITAL SODIUM 50 MG/ML INJ SOLN",0250,J2515,24201001050,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",121.07,191,fee schedule,999999999,20.37,2100,fee schedule,""
"PERPHENAZINE 2 MG PO TABS",0250,A9270,00904659961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.19 ,4.33 ,Aetna,"AETNA",2.79,45,percent of total billed charges,999999999,0.03087,4.333,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENAZOPYRIDINE HCL 100 MG PO TABS",0250,A9270,65162068110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENAZOPYRIDINE HCL 200 MG PO TABS",0250,A9270,65162068210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL 20 MG/5ML PO ELIX",0250,A9270,99999008199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL 20 MG/5ML PO ELIX",0250,A9270,16571067516,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.01 ,5.61 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL 32.4 MG PO TABS",0250,A9270,00904657561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL 97.2 MG PO TABS",0250,A9270,75826014210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN",0250,J2560,00641047721,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,220.36 ,154.25 ,Aetna,"AETNA",62.65,191,fee schedule,999999999,31.432,154.252,fee schedule,""
"PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN",0250,J2560,00641047725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,220.36 ,154.25 ,Aetna,"AETNA",62.65,191,fee schedule,999999999,31.432,154.252,fee schedule,""
"PHENOBARBITAL SODIUM 65 MG/ML INJ SOLN",0250,J2560,42494041525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,120,ME,,102.49 ,71.74 ,Aetna,"AETNA",62.65,191,fee schedule,999999999,30.747,71.743,fee schedule,""
"PHENYLEPHRINE HCL 0.25 % NA SOLN",0250,A9270,00225080047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,29.09 ,20.36 ,Aetna,"AETNA",13.09,45,percent of total billed charges,999999999,0.03087,20.363,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL 0.5 % NA SOLN",0250,A9270,00225080547,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,29.09 ,20.36 ,Aetna,"AETNA",13.09,45,percent of total billed charges,999999999,0.03087,20.363,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL 1 % NA SOLN",0250,A9270,00225081047,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,32.55 ,22.79 ,Aetna,"AETNA",14.65,45,percent of total billed charges,999999999,0.03087,22.785,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYLEPHRINE HCL 2.5 % OP SOLN",0250,,70756062925,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,147.78 ,103.45 ,Aetna,"AETNA",66.50,45,percent of total billed charges,999999999,44.334,103.446,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYTOIN 125 MG/5ML PO SUSP",0250,A9270,51672406901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYTOIN SODIUM 50 MG/ML INJ SOLN",0250,J1165,00641049321,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,6.03 ,4.22 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.45,5.6,fee schedule,""
"PHENYTOIN SODIUM 50 MG/ML INJ SOLN",0250,J1165,00641255541,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.45,5.6,fee schedule,""
"PHENYTOIN SODIUM 50 MG/ML INJ SOLN",0250,J1165,00641049325,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,8.00 ,5.60 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.45,5.6,fee schedule,""
"PHENYTOIN SODIUM 50 MG/ML INJ SOLN",0250,J1165,00641255545,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.22,191,fee schedule,999999999,0.45,5.6,fee schedule,""
"PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS",0250,A9270,51672411103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS",0250,A9270,00071036932,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,0.03087,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PHYSOSTIGMINE SALICYLATE 1 MG/ML INJ SOLN",0250,,17478051002,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,474.42 ,332.09 ,Aetna,"AETNA",213.49,45,percent of total billed charges,999999999,142.326,332.094,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PILOCARPINE HCL 1 % OP SOLN",0250,A9270,61314020315,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,236.52 ,165.56 ,Aetna,"AETNA",106.43,45,percent of total billed charges,999999999,0.03087,165.564,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PILOCARPINE HCL 2 % OP SOLN",0250,A9270,61314020415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,252.09 ,176.46 ,Aetna,"AETNA",113.44,45,percent of total billed charges,999999999,0.03087,176.463,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PILOCARPINE HCL 4 % OP SOLN",0250,A9270,61314020615,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,256.41 ,179.49 ,Aetna,"AETNA",115.38,45,percent of total billed charges,999999999,0.03087,179.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PINDOLOL 5 MG PO TABS",0250,A9270,76385013101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYMYXIN B SULFATE 500000 UNITS INJ SOLR",0250,,55150023410,RC,,NDC,FACILITY,OUTPATIENT,0.1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POLYSPORIN 500-10000 UNIT/GM EX OINT",0250,A9270,70000007001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,27.24 ,19.07 ,Aetna,"AETNA",12.26,45,percent of total billed charges,999999999,0.03087,19.068,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM ACETATE 2 MEQ/ML IV SOLN",0250,,00409329451,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,20.685,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM ACETATE 2 MEQ/ML IV SOLN",0250,,00409329461,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,68.95 ,48.27 ,Aetna,"AETNA",31.03,45,percent of total billed charges,999999999,20.685,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM BICARBONATE 25 MEQ PO TBEF",0250,A9270,00245532630,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM BICARBONATE 25 MEQ PO TBEF",0250,A9270,00245532689,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN",0250,J3480,00409665305,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,29.68 ,20.78 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,87.15,fee schedule,""
"POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN",0250,J3480,00264194020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,124.50 ,87.15 ,Aetna,"AETNA",0.21,191,fee schedule,999999999,0.1,87.15,fee schedule,""
"POVIDONE-IODINE 10 % EX OINT",0250,A9270,00536127180,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,10.54 ,7.38 ,Aetna,"AETNA",4.74,45,percent of total billed charges,999999999,0.03087,7.378,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"POVIDONE-IODINE 10 % EX SOLN",0250,A9270,00904110309,RC,HCPCS,NDC,FACILITY,OUTPATIENT,240,ML,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,0.03087,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRALIDOXIME CHLORIDE 1 G IV SOLR",0250,J2730,60977014101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ME,,484.36 ,339.05 ,Aetna,"AETNA",198.72,191,fee schedule,999999999,86.7,343.602,fee schedule,""
"PRALIDOXIME CHLORIDE 1 G IV SOLR",0250,J2730,60977014127,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ME,,490.86 ,343.60 ,Aetna,"AETNA",198.72,191,fee schedule,999999999,86.7,343.602,fee schedule,""
"PRAZOSIN HCL 1 MG PO CAPS",0250,A9270,70377006611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAZOSIN HCL 2 MG PO CAPS",0250,A9270,70377006711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRAZOSIN HCL 5 MG PO CAPS",0250,A9270,70377006811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE ACETATE 1 % OP SUSP",0250,,11980018005,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,828.90 ,580.23 ,Aetna,"AETNA",373.01,45,percent of total billed charges,999999999,75.618,967.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE ACETATE 1 % OP SUSP",0250,,11980018010,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,1381.50 ,967.05 ,Aetna,"AETNA",621.68,45,percent of total billed charges,999999999,75.618,967.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE ACETATE 1 % OP SUSP",0250,,60758011910,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,633.54 ,443.48 ,Aetna,"AETNA",285.09,45,percent of total billed charges,999999999,75.618,967.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE ACETATE 1 % OP SUSP",0250,,61314063710,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,252.06 ,176.44 ,Aetna,"AETNA",113.43,45,percent of total billed charges,999999999,75.618,967.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISOLONE SODIUM PHOSPHATE 1 % OP SOLN",0250,A9270,24208071510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,276.06 ,193.24 ,Aetna,"AETNA",124.23,45,percent of total billed charges,999999999,0.03087,193.242,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREDNISONE 1 MG PO TABS",0250,J7512,59746017106,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"PREDNISONE 10 MG PO TABS",0250,J7512,00904692361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"PREDNISONE 2.5 MG PO TABS",0250,J7512,00603533621,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"PREDNISONE 20 MG PO TABS",0250,J7512,00904712761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"PREDNISONE 5 MG PO TABS",0250,J7512,60687012201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"PREDNISONE 50 MG PO TABS",0250,J7512,64380094906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.02,191,fee schedule,999999999,0.007,3.5,fee schedule,""
"ASCORBIC ACID 500 MG/ML INJ SOLN",0250,,67457011850,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,493.50 ,345.45 ,Aetna,"AETNA",222.08,45,percent of total billed charges,999999999,148.05,345.45,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRIMIDONE 250 MG PO TABS",0250,A9270,53746054501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROBENECID 500 MG PO TABS",0250,A9270,00591534701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROCAINAMIDE HCL 100 MG/ML INJ SOLN",0250,J2690,00409190201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,331.86 ,232.30 ,Aetna,"AETNA",357.55,191,fee schedule,999999999,99.558,357.552,fee schedule,""
"PROCHLORPERAZINE MALEATE 10 MG PO TABS",0250,Q0164,50268068511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.35,3.5,fee schedule,""
"PROCHLORPERAZINE MALEATE 10 MG PO TABS",0250,Q0164,50268068515,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.35,3.5,fee schedule,""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS",0250,Q0164,50268068411,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,7.82 ,5.47 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.35,5.6,fee schedule,""
"PROCHLORPERAZINE MALEATE 5 MG PO TABS",0250,Q0164,50268068415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,8.00 ,5.60 ,Aetna,"AETNA",0.78,191,fee schedule,999999999,0.35,5.6,fee schedule,""
"PROMETHAZINE HCL 25 MG PO TABS",0250,A9270,00904730461,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 50 MG PR SUPP",0250,A9270,00713013212,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,133.76 ,93.63 ,Aetna,"AETNA",60.19,45,percent of total billed charges,999999999,0.03087,93.632,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROMETHAZINE HCL 50 MG PR SUPP",0250,A9270,00713013206,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,133.76 ,93.63 ,Aetna,"AETNA",60.19,45,percent of total billed charges,999999999,0.03087,93.632,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASCORBIC ACID 500 MG PO TABS",0250,A9270,40985022316,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPANTHELINE BROMIDE 15 MG PO TABS",0250,A9270,00054472125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16.41 ,11.49 ,Aetna,"AETNA",7.38,45,percent of total billed charges,999999999,0.03087,11.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPARACAINE HCL 0.5 % OP SOLN",0250,,61314001601,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,163.71 ,114.60 ,Aetna,"AETNA",73.67,45,percent of total billed charges,999999999,49.113,114.597,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 20 MG/5ML PO SOLN",0250,A9270,00054372763,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,273.00 ,191.10 ,Aetna,"AETNA",122.85,45,percent of total billed charges,999999999,0.03087,191.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 40 MG/5ML PO SOLN",0250,A9270,00054373063,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 10 MG PO TABS",0250,A9270,60687058701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 20 MG PO TABS",0250,A9270,60687059801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 40 MG PO TABS",0250,A9270,60687060901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 40 MG PO TABS",0250,A9270,60687060911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPRANOLOL HCL 80 MG PO TABS",0250,A9270,16714002504,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROPYLTHIOURACIL 50 MG PO TABS",0250,A9270,00228234810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PROTAMINE SULFATE 10 MG/ML IV SOLN",0250,J2720,63323022905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,35.00 ,24.50 ,Aetna,"AETNA",4.07,191,fee schedule,999999999,0.79,24.5,fee schedule,""
"PROTAMINE SULFATE 10 MG/ML IV SOLN",0250,J2720,63323022930,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,18.11 ,12.68 ,Aetna,"AETNA",4.07,191,fee schedule,999999999,0.79,24.5,fee schedule,""
"PSEUDOEPHEDRINE HCL 30 MG PO TABS",0250,A9270,00904699061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PSEUDOEPHEDRINE HCL 60 MG PO TABS",0250,A9270,00904690706,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PSEUDOEPHEDRINE HCL ER 120 MG PO TB12",0250,A9270,00904675415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRAZINAMIDE 500 MG PO TABS",0250,A9270,70954048410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,27.10 ,18.97 ,Aetna,"AETNA",12.20,45,percent of total billed charges,999999999,0.03087,18.97,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIDOXINE HCL 100 MG/ML INJ SOLN",0250,J3415,63323018001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,5.53 ,3.87 ,Aetna,"AETNA",28.65,191,fee schedule,999999999,1.659,28.65,fee schedule,""
"PYRIDOXINE HCL 25 MG PO TABS",0250,A9270,00536440601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PYRIDOXINE HCL 50 MG PO TABS",0250,A9270,77333094010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"QUININE SULFATE 324 MG PO CAPS",0250,A9270,68180056006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.09 ,7.06 ,Aetna,"AETNA",4.54,45,percent of total billed charges,999999999,0.03087,7.063,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN 81 MG PO CHEW",0250,A9270,00904679430,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN 325 MG PO TABS",0250,A9270,00536105429,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN 81 MG PO TBEC",0250,A9270,00904678370,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN 300 MG PR SUPP",0250,A9270,00574703412,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.77 ,6.84 ,Aetna,"AETNA",4.40,45,percent of total billed charges,999999999,0.03087,6.839,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN 600 MG PR SUPP",0250,A9270,00574703612,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,10.89 ,7.62 ,Aetna,"AETNA",4.90,45,percent of total billed charges,999999999,0.03087,7.623,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SALINE NASAL SPRAY 0.65 % NA SOLN",0250,A9270,45802035758,RC,HCPCS,NDC,FACILITY,OUTPATIENT,45,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATENOLOL 100 MG PO TABS",0250,A9270,51079068501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATENOLOL 100 MG PO TABS",0250,A9270,51079068520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATENOLOL 25 MG PO TABS",0250,A9270,00904718761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATENOLOL 50 MG PO TABS",0250,A9270,63304062201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SILVER SULFADIAZINE 1 % EX CREA",0250,A9270,67877012425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,20.48 ,14.34 ,Aetna,"AETNA",9.22,45,percent of total billed charges,999999999,0.03087,14.336,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMETHICONE 125 MG PO CHEW",0250,A9270,00536122308,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMETHICONE 40 MG/0.6ML PO SUSP",0250,A9270,00536130375,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMETHICONE 40 MG/0.6ML PO SUSP",0250,A9270,62372063015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SIMPLE SYRUP PO SYRP",0250,A9270,00395266116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,85.14 ,59.60 ,Aetna,"AETNA",38.31,45,percent of total billed charges,999999999,0.03087,59.598,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATROPINE SULFATE 0.1 MG/ML INJ SOLN",0250,J0461,00409163010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,23.72 ,16.60 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,16.604,fee schedule,""
"ATROPINE SULFATE 0.1 MG/ML INJ SOLN",0250,J0461,00409163015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.01,ME,,21.56 ,15.09 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,16.604,fee schedule,""
"SODIUM ACETATE 2 MEQ/ML IV SOLN",0250,J3490,00409729973,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,21.98 ,15.39 ,Aetna,"AETNA",9.89,45,percent of total billed charges,999999999,0,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ACETATE 2 MEQ/ML IV SOLN",0250,J3490,00409329905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,32.20 ,22.54 ,Aetna,"AETNA",14.49,45,percent of total billed charges,999999999,0,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ACETATE 2 MEQ/ML IV SOLN",0250,J3490,00409329906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,44.10 ,30.87 ,Aetna,"AETNA",19.85,45,percent of total billed charges,999999999,0,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM ACETATE 2 MEQ/ML IV SOLN",0250,J3490,00409329916,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,mEq,,41.30 ,28.91 ,Aetna,"AETNA",18.59,45,percent of total billed charges,999999999,0,30.87,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BENZOATE POWD",0250,A9270,51927123400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 4.2 % IV SOLN",0250,,63323008305,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,106.47 ,74.53 ,Aetna,"AETNA",47.91,45,percent of total billed charges,999999999,31.941,74.529,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 8.4 % IV SOLN",0250,J3490,00409663714,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,80.40 ,56.28 ,Aetna,"AETNA",36.18,45,percent of total billed charges,999999999,0,56.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 8.4 % IV SOLN",0250,J3490,51754500104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,0,56.28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE PO POWD",0250,,00395268594,RC,,NDC,FACILITY,OUTPATIENT,113,GR,,41.13 ,28.79 ,Aetna,"AETNA",18.51,45,percent of total billed charges,999999999,12.339,28.791,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 325 MG PO TABS",0250,A9270,00536454010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM BICARBONATE 650 MG PO TABS",0250,A9270,00904726161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 2.5 MEQ/ML INJ SOLN",0250,,00409666075,RC,,NDC,FACILITY,OUTPATIENT,40,ML,,11.48 ,8.04 ,Aetna,"AETNA",5.17,45,percent of total billed charges,999999999,3.444,8.036,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 4 MEQ/ML IV SOLN",0250,,00409114102,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,25.90 ,18.13 ,Aetna,"AETNA",11.66,45,percent of total billed charges,999999999,7.14,32.781,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 4 MEQ/ML IV SOLN",0250,,00409114112,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,23.80 ,16.66 ,Aetna,"AETNA",10.71,45,percent of total billed charges,999999999,7.14,32.781,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 4 MEQ/ML IV SOLN",0250,,63323009301,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,46.83 ,32.78 ,Aetna,"AETNA",21.07,45,percent of total billed charges,999999999,7.14,32.781,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 4 MEQ/ML IV SOLN",0250,,63323009330,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,46.83 ,32.78 ,Aetna,"AETNA",21.07,45,percent of total billed charges,999999999,7.14,32.781,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 3 % INH NEBU",0250,,76204002260,RC,,NDC,FACILITY,OUTPATIENT,3,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 1 G PO TABS",0250,A9270,77333084410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 1 G PO TABS",0250,A9270,77333084425,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN",0250,A9270,00536125494,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,30.14 ,21.10 ,Aetna,"AETNA",13.56,45,percent of total billed charges,999999999,0.03087,21.098,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN",0250,,00409739172,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,88.29 ,61.80 ,Aetna,"AETNA",39.73,45,percent of total billed charges,999999999,24.543,61.803,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN",0250,,00409739182,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,81.81 ,57.27 ,Aetna,"AETNA",36.81,45,percent of total billed charges,999999999,24.543,61.803,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFACETAMIDE SODIUM 10 % OP SOLN",0250,,24208067004,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,207.27 ,145.09 ,Aetna,"AETNA",93.27,45,percent of total billed charges,999999999,62.181,145.089,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ATROPINE SULFATE 1 % OP SOLN",0250,,60219174903,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,220.92 ,154.64 ,Aetna,"AETNA",99.41,45,percent of total billed charges,999999999,66.276,154.644,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE 25 MG PO TABS",0250,A9270,00904692761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SPIRONOLACTONE-HCTZ 25-25 MG PO TABS",0250,A9270,53489014401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.18 ,3.63 ,Aetna,"AETNA",2.33,45,percent of total billed charges,999999999,0.03087,3.626,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00409488750,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,11.90 ,8.33 ,Aetna,"AETNA",5.36,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00409488799,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,25.90 ,18.13 ,Aetna,"AETNA",11.66,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00338001304,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00338001306,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,42.00 ,29.40 ,Aetna,"AETNA",18.90,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00409488724,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,00409488725,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,63323018507,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,6.24 ,4.37 ,Aetna,"AETNA",2.81,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR INJECTION INJ SOLN",0250,,63323018510,RC,,NDC,FACILITY,OUTPATIENT,50,ML,,6.24 ,4.37 ,Aetna,"AETNA",2.81,45,percent of total billed charges,999999999,1.872,29.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"STERILE WATER FOR IRRIGATION IR SOLN",0250,,00338000404,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN",0250,J0330,70069030125,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,8.33 ,5.83 ,Aetna,"AETNA",1.85,191,fee schedule,999999999,0.81,5.831,fee schedule,""
"SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN",0250,J0330,70069030101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,8.33 ,5.83 ,Aetna,"AETNA",1.85,191,fee schedule,999999999,0.81,5.831,fee schedule,""
"SULFADIAZINE 500 MG PO TABS",0250,A9270,42806075760,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,98.18 ,68.73 ,Aetna,"AETNA",44.18,45,percent of total billed charges,999999999,0.03087,68.726,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN",0250,,00703951401,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,52.668,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN",0250,,00703951403,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,75.24 ,52.67 ,Aetna,"AETNA",33.86,45,percent of total billed charges,999999999,21,52.668,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS",0250,A9270,50268072811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS",0250,A9270,50268072815,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFASALAZINE 500 MG PO TABS",0250,A9270,59762500005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SULFASALAZINE 500 MG PO TBEC",0250,A9270,59762010405,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SURGILUBE EX GEL",0250,A9270,00281020502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,56.7,GR,,18.65 ,13.06 ,Aetna,"AETNA",8.39,45,percent of total billed charges,999999999,0.03087,13.055,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZATHIOPRINE SODIUM 100 MG INJ SOLR",0250,J7501,00143956601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,1026.55 ,718.59 ,Aetna,"AETNA",573.00,191,fee schedule,999999999,250,718.585,fee schedule,""
"TALC POWD",0250,,00395290111,RC,,NDC,FACILITY,OUTPATIENT,300,GR,,97.20 ,68.04 ,Aetna,"AETNA",43.74,45,percent of total billed charges,999999999,14.49,68.04,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TALC POWD",0250,,0395290110,RC,,NDC,FACILITY,OUTPATIENT,300,GR,,48.30 ,33.81 ,Aetna,"AETNA",21.74,45,percent of total billed charges,999999999,14.49,68.04,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TAMOXIFEN CITRATE 10 MG PO TABS",0250,A9270,63739014310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TEMAZEPAM 15 MG PO CAPS",0250,A9270,00228207610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETRACAINE HCL 0.5 % OP SOLN",0250,,00065074114,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETRACYCLINE HCL 500 MG PO CAPS",0250,A9270,23155076701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.07 ,3.55 ,Aetna,"AETNA",2.28,45,percent of total billed charges,999999999,0.03087,3.549,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TETRAHYDROZOLINE HCL 0.05 % OP SOLN",0250,A9270,00536121794,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ML,,11.45 ,8.02 ,Aetna,"AETNA",5.15,45,percent of total billed charges,999999999,0.03087,8.015,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THEOPHYLLINE 80 MG/15ML PO SOLN",0250,A9270,27808003301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.44 ,5.91 ,Aetna,"AETNA",3.80,45,percent of total billed charges,999999999,0.03087,5.908,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THERAPEUTIC MULTIVIT/MINERAL PO TABS",0250,A9270,40985022368,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THIAMINE HCL 100 MG/ML INJ SOLN",0250,J3411,00641622801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,6.01 ,4.21 ,Aetna,"AETNA",4.32,191,fee schedule,999999999,1.803,4.3166,fee schedule,""
"THIAMINE HCL 100 MG/ML INJ SOLN",0250,J3411,00641622825,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,6.01 ,4.21 ,Aetna,"AETNA",4.32,191,fee schedule,999999999,1.803,4.3166,fee schedule,""
"THIOGUANINE 40 MG PO TABS",0250,A9270,80725063025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,625,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THIOTEPA 15 MG INJ SOLR",0250,J9340,53964000101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",436.17,191,fee schedule,999999999,247.75,2100,fee schedule,""
"THYROID 120 MG PO TABS",0250,A9270,62559074401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"THYROID 30 MG PO TABS",0250,A9270,62559074101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN SULFATE 10 MG/ML INJ SOLN",0250,J3260,63323030502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,32.23 ,22.56 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.6,22.561,fee schedule,""
"INTRAOP VANCOMYCIN IN 0.9% NACL IVPB",0250,J3370,67457034001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,6.73 ,4.71 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.019,4.9278,fee schedule,""
"INTRAOP VANCOMYCIN IN 0.9% NACL IVPB",0250,J3370,67457034000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,6.73 ,4.71 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.019,4.9278,fee schedule,""
"INTRAOP OXYTOCIN 20 UNITS/1000 ML LR",0250,J2590,99999014199,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,28.00 ,19.60 ,Aetna,"AETNA",3.21,191,fee schedule,999999999,1.4,19.6,fee schedule,""
"INTRAOP ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028565,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,3.5,fee schedule,""
"INTRAOP ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,63323028561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,3.5,fee schedule,""
"INTRAOP ROPIVACAINE HCL 2 MG/ML INJ SOLN",0250,J2795,99999023799,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,3.5,fee schedule,""
"INTRAOP CLINDAMYCIN PHOSPHATE INJ SOLN",0250,,00009090211,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,9.11 ,6.38 ,Aetna,"AETNA",4.10,45,percent of total billed charges,999999999,2.733,8.701,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP CLINDAMYCIN PHOSPHATE INJ SOLN",0250,,00009090218,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,9.25 ,6.48 ,Aetna,"AETNA",4.16,45,percent of total billed charges,999999999,2.733,8.701,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP CLINDAMYCIN PHOSPHATE INJ SOLN",0250,,00009087021,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,12.43 ,8.70 ,Aetna,"AETNA",5.59,45,percent of total billed charges,999999999,2.733,8.701,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN",0250,J0330,70004091029,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,42.75 ,29.93 ,Aetna,"AETNA",1.85,191,fee schedule,999999999,0.81,29.925,fee schedule,""
"INTRAOP SUFENTANIL CITRATE 50 MCG/ML IV SOLN",0250,,00409338221,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,91.45 ,64.02 ,Aetna,"AETNA",41.15,45,percent of total billed charges,999999999,14.385,66.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP SUFENTANIL CITRATE 50 MCG/ML IV SOLN",0250,,17478005001,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,56.77 ,39.74 ,Aetna,"AETNA",25.55,45,percent of total billed charges,999999999,14.385,66.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP SUFENTANIL CITRATE 50 MCG/ML IV SOLN",0250,,17478005002,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,47.95 ,33.57 ,Aetna,"AETNA",21.58,45,percent of total billed charges,999999999,14.385,66.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP SUFENTANIL CITRATE 50 MCG/ML IV SOLN",0250,,00641611201,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,95.04 ,66.53 ,Aetna,"AETNA",42.77,45,percent of total billed charges,999999999,14.385,66.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP PROPOFOL 10 MG/ML IV",0250,,63323026965,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,1.5,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP PROPOFOL 10 MG/ML IV",0250,,63323026950,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP PROPOFOL 10 MG/ML IV",0250,,63323026929,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,14.42 ,10.09 ,Aetna,"AETNA",6.49,45,percent of total billed charges,999999999,1.5,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP ROCURONIUM BROMIDE IV SOLN",0250,,00409955805,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,5.92 ,4.14 ,Aetna,"AETNA",2.66,45,percent of total billed charges,999999999,1.5,4.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP ROCURONIUM BROMIDE IV SOLN",0250,,00781322092,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,4.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP ROCURONIUM BROMIDE IV SOLN",0250,,39822420005,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,6.41 ,4.49 ,Aetna,"AETNA",2.88,45,percent of total billed charges,999999999,1.5,4.487,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP GLYCOPYRROLATE 0.2 MG/ML INJ SOLN",0250,J1596,00143968225,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,13.685,fee schedule,""
"INTRAOP GLYCOPYRROLATE 0.2 MG/ML INJ SOLN",0250,J1596,00143968025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,13.685,fee schedule,""
"INTRAOP GLYCOPYRROLATE 0.2 MG/ML INJ SOLN",0250,J1596,00143968101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,19.55 ,13.69 ,Aetna,"AETNA",0.96,191,fee schedule,999999999,0.54,13.685,fee schedule,""
"INTRAOP ADENOSINE 3 MG/ML IV SOLN",0250,J0153,63323065104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,30.52 ,21.36 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,21.364,fee schedule,""
"INTRAOP ADENOSINE 3 MG/ML IV SOLN",0250,J0153,67457085502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.29 ,3.70 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,21.364,fee schedule,""
"INTRAOP ADENOSINE 3 MG/ML IV SOLN",0250,J0153,67457085500,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.29 ,3.70 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,21.364,fee schedule,""
"INTRAOP ADENOSINE 3 MG/ML IV SOLN",0250,J0153,55150019301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.07,191,fee schedule,999999999,0.44,21.364,fee schedule,""
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,00409132305,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,31.47 ,22.03 ,Aetna,"AETNA",14.16,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,00409490334,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,36.96 ,25.87 ,Aetna,"AETNA",16.63,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,63323048617,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,13.37 ,9.36 ,Aetna,"AETNA",6.02,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,63323048602,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,00409132315,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,28.63 ,20.04 ,Aetna,"AETNA",12.88,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP LIDOCAINE HCL 20 MG/ML IV SOLN",0250,,63323020202,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,53.73 ,37.61 ,Aetna,"AETNA",24.18,45,percent of total billed charges,999999999,1.5,37.611,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP BUPIVACAINE HCL-NACL 0.125-0.9 % EPID SOLN",0250,J3490,99999032899,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP ROPIVACAINE HCL 2.5 MG/ML IN NS INJ SOLN",0250,J2795,99999032999,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,26.92 ,18.84 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.07,18.844,fee schedule,""
"INTRAOP FENTANYL OR INFUSION",0250,,00409909431,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,25.20 ,17.64 ,Aetna,"AETNA",11.34,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP FENTANYL OR INFUSION",0250,,00409909332,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP FENTANYL OR INFUSION",0250,,00409909422,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP FENTANYL OR INFUSION",0250,,00409909425,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,7.96 ,5.57 ,Aetna,"AETNA",3.58,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP FENTANYL OR INFUSION",0250,,00409909412,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP FENTANYL OR INFUSION",0250,,00409909418,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,7.76 ,5.43 ,Aetna,"AETNA",3.49,45,percent of total billed charges,999999999,1.5,17.64,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP KETAMINE HCL 50 MG/ML INJ SOLN",0250,,00143950801,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP KETAMINE HCL 50 MG/ML INJ SOLN",0250,,00143950810,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP KETAMINE HCL 50 MG/ML INJ SOLN",0250,,70092112043,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,15.09 ,10.56 ,Aetna,"AETNA",6.79,45,percent of total billed charges,999999999,1.5,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP KETAMINE HCL 50 MG/ML INJ SOLN",0250,,70092912043,RC,,NDC,FACILITY,OUTPATIENT,0.5,ML,,23.80 ,16.66 ,Aetna,"AETNA",10.71,45,percent of total billed charges,999999999,1.5,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOLBUTAMIDE 500 MG PO TABS",0250,A9270,00378021501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.70 ,5.39 ,Aetna,"AETNA",3.47,45,percent of total billed charges,999999999,0.03087,5.39,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOLNAFTATE 1 % EX CREA",0250,A9270,10939563330,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.33 ,10.73 ,Aetna,"AETNA",6.90,45,percent of total billed charges,999999999,0.03087,10.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOLNAFTATE 1 % EX CREA",0250,A9270,49348015529,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.33 ,10.73 ,Aetna,"AETNA",6.90,45,percent of total billed charges,999999999,0.03087,10.731,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOLNAFTATE 1 % EX POWD",0250,,00536132926,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,15.12 ,10.58 ,Aetna,"AETNA",6.80,45,percent of total billed charges,999999999,4.536,10.584,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HYDROCHLOROTHIAZIDE 12.5 MG PO TABS",0250,A9270,23155076401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALISKIREN FUMARATE 150 MG PO TABS",0250,A9270,70839015030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,68.82 ,48.17 ,Aetna,"AETNA",30.97,45,percent of total billed charges,999999999,0.03087,48.174,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALAMINE 8-8 % EX LOTN",0250,A9270,00904253321,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,12.39 ,8.67 ,Aetna,"AETNA",5.58,45,percent of total billed charges,999999999,0.03087,8.673,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAZODONE HCL 100 MG PO TABS",0250,A9270,00904686961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAZODONE HCL 150 MG PO TABS",0250,A9270,00904721261,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAZODONE HCL 50 MG PO TABS",0250,A9270,00904686861,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DENTAL WAX WAX",0250,A9270,47701000033,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.75 ,6.13 ,Aetna,"AETNA",3.94,45,percent of total billed charges,999999999,0.03087,6.125,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 0.025 % EX CREA",0250,A9270,00168000315,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,14.18 ,9.93 ,Aetna,"AETNA",6.38,45,percent of total billed charges,999999999,0.03087,9.926,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 0.1 % EX CREA",0250,A9270,67877025115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,11.34 ,7.94 ,Aetna,"AETNA",5.10,45,percent of total billed charges,999999999,0.03087,7.938,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 0.5 % EX CREA",0250,A9270,00168000215,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,36.02 ,25.21 ,Aetna,"AETNA",16.21,45,percent of total billed charges,999999999,0.03087,36.897,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 0.5 % EX CREA",0250,A9270,45802006535,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,52.71 ,36.90 ,Aetna,"AETNA",23.72,45,percent of total billed charges,999999999,0.03087,36.897,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 0.1 % EX OINT",0250,A9270,33342033315,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,13.23 ,9.26 ,Aetna,"AETNA",5.95,45,percent of total billed charges,999999999,0.03087,9.261,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP",0250,J3301,81298578105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,22.16 ,15.51 ,Aetna,"AETNA",2.06,191,fee schedule,999999999,0.946,15.512,fee schedule,""
"TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP",0250,J3301,81298578101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,22.16 ,15.51 ,Aetna,"AETNA",2.06,191,fee schedule,999999999,0.946,15.512,fee schedule,""
"TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE",0250,A9270,00713065540,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,GR,,471.84 ,330.29 ,Aetna,"AETNA",212.33,45,percent of total billed charges,999999999,0.03087,330.288,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMTERENE-HCTZ 37.5-25 MG PO TABS",0250,A9270,68084075025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAMTERENE-HCTZ 37.5-25 MG PO TABS",0250,A9270,68084075095,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIAZOLAM 0.25 MG PO TABS",0250,A9270,70710128901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZOLEDRONIC ACID 5 MG/100ML IV SOLN",0250,J3489,51991006498,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,2304.00 ,1612.80 ,Aetna,"AETNA",13.26,191,fee schedule,999999999,6.93,1612.8,fee schedule,""
"TRIFLUOPERAZINE HCL 10 MG PO TABS",0250,A9270,00378241001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIHEXYPHENIDYL HCL 2 MG PO TABS",0250,A9270,70954021210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIHEXYPHENIDYL HCL 5 MG PO TABS",0250,A9270,70954021110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ECULIZUMAB 300 MG/30ML IV SOLN",0250,J1300,25682000101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,19568.97 ,13698.28 ,Aetna,"AETNA",431.09,191,fee schedule,999999999,225.26,13698.279,fee schedule,""
"TRIPLE ANTIBIOTIC 5-400-5000 EX OINT",0250,A9270,45802014301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,GR,,11.37 ,7.96 ,Aetna,"AETNA",5.12,45,percent of total billed charges,999999999,0.03087,7.959,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GLUCOSE 40 % PO GEL",0250,A9270,54758006285,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3,ML,,15.18 ,10.63 ,Aetna,"AETNA",6.83,45,percent of total billed charges,999999999,0.03087,10.626,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIPROLIDINE-PSE 2.5-60 MG PO TABS",0250,A9270,00904025024,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRIPROLIDINE-PSE 2.5-60 MG PO TABS",0250,A9270,00904025059,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUTICASONE FUROATE 27.5 MCG/SPRAY NA SUSP",0250,A9270,00135061502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,9.1,ML,,76.57 ,53.60 ,Aetna,"AETNA",34.46,45,percent of total billed charges,999999999,0.03087,53.599,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESMOLOL HCL 100 MG/10ML IV SOLN",0250,J1805,55150019410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,12.67 ,8.87 ,Aetna,"AETNA",0.42,191,fee schedule,999999999,0.24,8.869,fee schedule,""
"TROPICAMIDE 0.5 % OP SOLN",0250,,61314035401,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,134.55 ,94.19 ,Aetna,"AETNA",60.55,45,percent of total billed charges,999999999,40.365,94.185,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TROPICAMIDE 1 % OP SOLN",0250,,70069012101,RC,,NDC,FACILITY,OUTPATIENT,15,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 7 % INH NEBU",0250,,76204002160,RC,,NDC,FACILITY,OUTPATIENT,4,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOROURACIL 500 MG/10ML IV SOLN",0250,J9190,16729027603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,93.30 ,65.31 ,Aetna,"AETNA",5.63,191,fee schedule,999999999,1.83,104.244,fee schedule,""
"FLUOROURACIL 500 MG/10ML IV SOLN",0250,J9190,63323011710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,148.92 ,104.24 ,Aetna,"AETNA",5.63,191,fee schedule,999999999,1.83,104.244,fee schedule,""
"FLUOROURACIL 1 GM/20ML IV SOLN",0250,J9190,63323011720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,267.72 ,187.40 ,Aetna,"AETNA",5.63,191,fee schedule,999999999,1.83,187.404,fee schedule,""
"TEMSIROLIMUS 25 MG/ML IV SOLN",0250,J9330,00008117901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,14627.33 ,10239.13 ,Aetna,"AETNA",55.12,191,fee schedule,999999999,29.68,10239.131,fee schedule,""
"CLINDAMYCIN PHOSPHATE 900 MG/6ML INJ SOLN",0250,J0736,00009090211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,27.34 ,19.14 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,19.432,fee schedule,""
"CLINDAMYCIN PHOSPHATE 900 MG/6ML INJ SOLN",0250,J0736,00009090218,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,27.76 ,19.43 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,19.432,fee schedule,""
"AMBRISENTAN 5 MG PO TABS",0250,A9270,47335023683,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,270.00 ,189.00 ,Aetna,"AETNA",121.50,45,percent of total billed charges,999999999,0.03087,189,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMBRISENTAN 10 MG PO TABS",0250,A9270,47335023783,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,270.00 ,189.00 ,Aetna,"AETNA",121.50,45,percent of total billed charges,999999999,0.03087,189,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MELATONIN 1 MG PO TABS",0250,A9270,80681004100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BSS PLUS IO SOLN",0250,,00065080050,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,387.00 ,270.90 ,Aetna,"AETNA",174.15,45,percent of total billed charges,999999999,116.1,270.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST GLUCOSE CONTROL PO LIQD",0250,,43900036011,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,13.27 ,9.29 ,Aetna,"AETNA",5.97,45,percent of total billed charges,999999999,3.981,9.289,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST GLUCOSE CONTROL PO LIQD",0250,,43900036021,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,13.27 ,9.29 ,Aetna,"AETNA",5.97,45,percent of total billed charges,999999999,3.981,9.289,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BOOST GLUCOSE CONTROL PO LIQD",0250,,43900036031,RC,,NDC,FACILITY,OUTPATIENT,237,ML,,13.27 ,9.29 ,Aetna,"AETNA",5.97,45,percent of total billed charges,999999999,3.981,9.289,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MARAVIROC 300 MG PO TABS",0250,A9270,49702022418,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,168.68 ,118.08 ,Aetna,"AETNA",75.91,45,percent of total billed charges,999999999,0.03087,118.076,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPIRUBICIN HCL 50 MG/25ML IV SOLN",0250,J9178,00009509101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,187.65 ,131.36 ,Aetna,"AETNA",2.54,191,fee schedule,999999999,1.34,131.355,fee schedule,""
"FOSPHENYTOIN SODIUM 500 MG PE/10ML INJ SOLN",0250,Q2009,00069600110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,150.60 ,105.42 ,Aetna,"AETNA",7.16,191,fee schedule,999999999,2.5,474.306,fee schedule,""
"FOSPHENYTOIN SODIUM 500 MG PE/10ML INJ SOLN",0250,Q2009,00069600121,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,677.58 ,474.31 ,Aetna,"AETNA",7.16,191,fee schedule,999999999,2.5,474.306,fee schedule,""
"FOSPHENYTOIN SODIUM 100 MG PE/2ML INJ SOLN",0250,Q2009,00641613601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,16.84 ,11.79 ,Aetna,"AETNA",7.16,191,fee schedule,999999999,2.5,11.788,fee schedule,""
"FOSPHENYTOIN SODIUM 100 MG PE/2ML INJ SOLN",0250,Q2009,00641613625,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,16.84 ,11.79 ,Aetna,"AETNA",7.16,191,fee schedule,999999999,2.5,11.788,fee schedule,""
"ANIDULAFUNGIN 100 MG IV SOLR",0250,J0348,00049011628,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,844.68 ,591.28 ,Aetna,"AETNA",0.88,191,fee schedule,999999999,0.46,591.276,fee schedule,""
"IDARUBICIN HCL 5 MG/5ML IV SOLN",0250,J9211,00013257691,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,219.54 ,153.68 ,Aetna,"AETNA",74.38,191,fee schedule,999999999,33.9,153.678,fee schedule,""
"IDARUBICIN HCL 10 MG/10ML IV SOLN",0250,J9211,00703415511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,301.32 ,210.92 ,Aetna,"AETNA",74.38,191,fee schedule,999999999,33.9,210.924,fee schedule,""
"IDARUBICIN HCL 20 MG/20ML IV SOLN",0250,J9211,00013259691,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,882.00 ,617.40 ,Aetna,"AETNA",74.38,191,fee schedule,999999999,33.9,617.4,fee schedule,""
"VALPROIC ACID 250 MG PO CAPS",0250,A9270,63739008610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INSULIN GLULISINE 100 UNIT/ML INJ SOLN",0250,J1815,00088250033,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,471.18 ,329.83 ,Aetna,"AETNA",0.52,191,fee schedule,999999999,0.31,329.826,fee schedule,""
"VANCOMYCIN HCL 500 MG IV SOLR",0250,J3370,67457033950,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,10.94 ,7.66 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,7.658,fee schedule,""
"VANCOMYCIN HCL 500 MG IV SOLR",0250,J3370,67457033900,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,10.94 ,7.66 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.09,7.658,fee schedule,""
"ANTIHEMOPHILIC FACTOR-VWF 1000 UNITS IV SOLR",0250,J7186,68516460302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,5.84 ,4.09 ,Aetna,"AETNA",2.27,191,fee schedule,999999999,1.15,4.088,fee schedule,""
"CISPLATIN 50 MG/50ML IV SOLN",0250,J9060,16729028811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,108.90 ,76.23 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,157.29,fee schedule,""
"CISPLATIN 50 MG/50ML IV SOLN",0250,J9060,63323010351,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,224.70 ,157.29 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,157.29,fee schedule,""
"CISPLATIN 100 MG/100ML IV SOLN",0250,J9060,00703574811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,218.40 ,152.88 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,273,fee schedule,""
"CISPLATIN 100 MG/100ML IV SOLN",0250,J9060,16729028838,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,181.20 ,126.84 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,273,fee schedule,""
"CISPLATIN 100 MG/100ML IV SOLN",0250,J9060,63323010365,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,390.00 ,273.00 ,Aetna,"AETNA",6.25,191,fee schedule,999999999,1.92,273,fee schedule,""
"LANREOTIDE ACETATE 90 MG/0.3ML SC SOLN",0250,J1930,15054109004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,23277.00 ,16293.90 ,Aetna,"AETNA",91.68,191,fee schedule,999999999,48.443,16293.9,fee schedule,""
"LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN",0250,J1930,15054112004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,28576.98 ,20003.89 ,Aetna,"AETNA",91.68,191,fee schedule,999999999,48.443,20003.886,fee schedule,""
"BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT",0250,A9270,24208078555,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.5,GR,,107.04 ,74.93 ,Aetna,"AETNA",48.17,45,percent of total billed charges,999999999,32.112,74.928,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LANREOTIDE ACETATE 60 MG/0.2ML SC SOLN",0250,J1930,15054106004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,17478.00 ,12234.60 ,Aetna,"AETNA",91.68,191,fee schedule,999999999,48.443,12234.6,fee schedule,""
"RALTEGRAVIR POTASSIUM 400 MG PO TABS",0250,A9270,00006022761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,194.69 ,136.28 ,Aetna,"AETNA",87.61,45,percent of total billed charges,999999999,0.03087,136.283,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IXABEPILONE 15 MG IV SOLR",0250,J9207,00015191012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3507.75 ,2455.43 ,Aetna,"AETNA",243.53,191,fee schedule,999999999,116.74,2455.425,fee schedule,""
"IXABEPILONE 45 MG IV SOLR",0250,J9207,00015191113,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9871.47 ,6910.03 ,Aetna,"AETNA",243.53,191,fee schedule,999999999,116.74,6910.029,fee schedule,""
"OSELTAMIVIR PHOSPHATE 30 MG PO CAPS",0250,A9270,68180067511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.60 ,4.62 ,Aetna,"AETNA",2.97,45,percent of total billed charges,999999999,0.03087,4.62,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACITRACIN 50000 UNITS IM SOLR",0250,,70594002602,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,21.40 ,14.98 ,Aetna,"AETNA",9.63,45,percent of total billed charges,999999999,6.42,14.98,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACITRACIN 500 UNIT/GM OP OINT",0250,,00574402235,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,648.54 ,453.98 ,Aetna,"AETNA",291.84,45,percent of total billed charges,999999999,194.562,453.978,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN",0250,J3490,70710164307,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,8.93 ,6.25 ,Aetna,"AETNA",4.02,45,percent of total billed charges,999999999,0,6.251,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL 2.5 MG/ML IV SOLN",0250,J3490,70710164301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,8.93 ,6.25 ,Aetna,"AETNA",4.02,45,percent of total billed charges,999999999,0,6.251,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL 120 MG PO TABS",0250,A9270,23155048601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VERAPAMIL HCL 80 MG PO TABS",0250,A9270,23155002601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT",0250,,01254723813,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,1.2,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT",0250,,24208055555,RC,,NDC,FACILITY,OUTPATIENT,3.5,GR,,126.55 ,88.59 ,Aetna,"AETNA",56.95,45,percent of total billed charges,999999999,37.965,88.585,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VINBLASTINE SULFATE 1 MG/ML IV SOLN",0250,J9360,63323027810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,222.36 ,155.65 ,Aetna,"AETNA",9.59,191,fee schedule,999999999,3.91,155.652,fee schedule,""
"VINCRISTINE SULFATE 1 MG/ML IV SOLN",0250,J9370,61703030906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,90.72 ,63.50 ,Aetna,"AETNA",15.11,191,fee schedule,999999999,4.88,63.504,fee schedule,""
"VINCRISTINE SULFATE 1 MG/ML IV SOLN",0250,J9370,61703030916,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,72.48 ,50.74 ,Aetna,"AETNA",15.11,191,fee schedule,999999999,4.88,63.504,fee schedule,""
"BACLOFEN 10 MG PO TABS",0250,A9270,00904647561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 800 MG PO TABS",0250,A9270,00904670706,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.92 ,6.24 ,Aetna,"AETNA",4.01,45,percent of total billed charges,999999999,0.03087,6.244,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN B-1 50 MG PO TABS",0250,A9270,80681009700,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN B-12 100 MCG PO TABS",0250,A9270,50268085215,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN B-12 100 MCG PO TABS",0250,A9270,50268085211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN B-12 500 MCG PO TABS",0250,A9270,77333093710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN B-12 500 MCG PO TABS",0250,A9270,77333093725,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOPIDOGREL BISULFATE 300 MG PO TABS",0250,A9270,00904646710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,39.49 ,27.64 ,Aetna,"AETNA",17.77,45,percent of total billed charges,999999999,0.03087,27.643,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PEMETREXED DISODIUM 100 MG IV SOLR",0250,J9305,00002764001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",7.58,191,fee schedule,999999999,3.22,2100,fee schedule,""
"OXYCODONE HCL 10 MG PO TABS",0250,A9270,68084096801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.37 ,3.76 ,Aetna,"AETNA",2.42,45,percent of total billed charges,999999999,0.03087,3.759,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXYCODONE HCL 10 MG PO TABS",0250,A9270,68084096811,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.10 ,3.57 ,Aetna,"AETNA",2.30,45,percent of total billed charges,999999999,0.03087,3.759,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN K1 10 MG/ML INJ SOLN",0250,J3430,69097070896,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,24.39 ,17.07 ,Aetna,"AETNA",5.35,191,fee schedule,999999999,2.87,17.073,fee schedule,""
"LISDEXAMFETAMINE DIMESYLATE 20 MG PO CAPS",0250,A9270,57664004788,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,23.60 ,16.52 ,Aetna,"AETNA",10.62,45,percent of total billed charges,999999999,0.03087,16.52,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 10 MG PO TABS",0250,A9270,00093172001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 2 MG PO TABS",0250,A9270,00832121201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 2.5 MG PO TABS",0250,A9270,00832121301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 5 MG PO TABS",0250,A9270,00832121601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"WARFARIN SODIUM 7.5 MG PO TABS",0250,A9270,00093172301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IRINOTECAN HCL 100 MG/5ML IV SOLN",0250,J9206,00009752903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,119.70 ,83.79 ,Aetna,"AETNA",6.70,191,fee schedule,999999999,1.945,83.79,fee schedule,""
"IRINOTECAN HCL 100 MG/5ML IV SOLN",0250,J9206,00143970101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,76.08 ,53.26 ,Aetna,"AETNA",6.70,191,fee schedule,999999999,1.945,83.79,fee schedule,""
"IRINOTECAN HCL 40 MG/2ML IV SOLN",0250,J9206,60505612800,RC,HCPCS,NDC,FACILITY,OUTPATIENT,20,ME,,46.13 ,32.29 ,Aetna,"AETNA",6.70,191,fee schedule,999999999,1.945,32.291,fee schedule,""
"SECRETIN ACETATE (HUMAN) 16 MCG IV SOLR",0250,J2850,67066000501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,2520.00 ,1764.00 ,Aetna,"AETNA",75.22,191,fee schedule,999999999,33.47,1764,fee schedule,""
"CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN",0250,J0744,00409330001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,9.10 ,6.37 ,Aetna,"AETNA",3.55,191,fee schedule,999999999,1.28,6.37,fee schedule,""
"CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN",0250,J0744,00409330024,RC,HCPCS,NDC,FACILITY,OUTPATIENT,200,ME,,9.10 ,6.37 ,Aetna,"AETNA",3.55,191,fee schedule,999999999,1.28,6.37,fee schedule,""
"BENDAMUSTINE HCL 100 MG IV SOLR",0250,J9033,63459039120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,9361.17 ,6552.82 ,Aetna,"AETNA",15.97,191,fee schedule,999999999,9.07,6552.819,fee schedule,""
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN",0250,J2212,65649055102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,572.96 ,401.07 ,Aetna,"AETNA",3.06,191,fee schedule,999999999,1.28,401.093,fee schedule,""
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN",0250,J2212,65649055103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,572.99 ,401.09 ,Aetna,"AETNA",3.06,191,fee schedule,999999999,1.28,401.093,fee schedule,""
"METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN",0250,J2212,65649055107,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,572.96 ,401.07 ,Aetna,"AETNA",3.06,191,fee schedule,999999999,1.28,401.093,fee schedule,""
"ZINC OXIDE 20 % EX OINT",0250,A9270,00536131628,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,12.60 ,8.82 ,Aetna,"AETNA",5.67,45,percent of total billed charges,999999999,0.03087,8.82,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZINC SULFATE 5 MG/ML IV SOLN",0250,,66794023902,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,160.50 ,112.35 ,Aetna,"AETNA",72.23,45,percent of total billed charges,999999999,48.15,112.35,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZINC SULFATE 5 MG/ML IV SOLN",0250,,66794023942,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,160.50 ,112.35 ,Aetna,"AETNA",72.23,45,percent of total billed charges,999999999,48.15,112.35,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ZINC SULFATE 220 (50 ZN) MG PO CAPS",0250,A9270,20555004000,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"REGADENOSON 0.4 MG/5ML IV SOLN",0250,J2785,76329332100,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,70.00 ,49.00 ,Aetna,"AETNA",13.47,191,fee schedule,999999999,7.65,62.28,fee schedule,""
"ALVIMOPAN 12 MG PO CAPS",0250,A9270,67919002010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,909.20 ,636.44 ,Aetna,"AETNA",409.14,45,percent of total billed charges,999999999,0.03087,636.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DTAP-IPV-HIB VACCINE IM SUSR",0250,90698,49281051105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ML,,408.74 ,286.12 ,Aetna,"AETNA",183.93,45,percent of total billed charges,999999999,102.185,286.118,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METOPROLOL TARTRATE 5 MG/5ML IV SOLN",0250,,36000003310,RC,,NDC,FACILITY,OUTPATIENT,2.5,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACEBUTOLOL HCL 200 MG PO CAPS",0250,A9270,53746066901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 160 MG/5ML PO SUSP",0250,A9270,00536132197,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,11.151,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 160 MG/5ML PO SUSP",0250,A9270,00904727870,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,15.93 ,11.15 ,Aetna,"AETNA",7.17,45,percent of total billed charges,999999999,0.03087,11.151,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS",0250,A9270,70010014901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAZOLAMIDE ER 500 MG PO CP12",0250,A9270,42571024301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETIC ACID 0.25 % IR SOLN",0250,,00338065604,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR",0250,J7189,00169720101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,mcg,,6700.56 ,4690.39 ,Aetna,"AETNA",4.68,191,fee schedule,999999999,2.35,4690.392,fee schedule,""
"ACYCLOVIR 200 MG PO CAPS",0250,A9270,00904578961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACYCLOVIR 200 MG/5ML PO SUSP",0250,A9270,70954018810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.16 ,5.71 ,Aetna,"AETNA",3.67,45,percent of total billed charges,999999999,0.03087,5.712,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACYCLOVIR 400 MG PO TABS",0250,A9270,00904579061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACYCLOVIR 800 MG PO TABS",0250,A9270,68084010901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,6.20 ,4.34 ,Aetna,"AETNA",2.79,45,percent of total billed charges,999999999,0.03087,4.34,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACYCLOVIR 800 MG PO TABS",0250,A9270,68084010911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,4.34,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ALBENDAZOLE 200 MG PO TABS",0250,A9270,31722093502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,98.73 ,69.11 ,Aetna,"AETNA",44.43,45,percent of total billed charges,999999999,0.03087,69.111,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ANTIHEM FACT (BDD-RFVIII,MOR) 250 UNITS IV KIT",0250,J7185,58394001201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,1032.65 ,722.86 ,Aetna,"AETNA",2.62,191,fee schedule,999999999,1.26,722.855,fee schedule,""
"ANTIHEM FACT (BDD-RFVIII,MOR) 250 UNITS IV KIT",0250,J7185,58394002203,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,900.00 ,630.00 ,Aetna,"AETNA",2.62,191,fee schedule,999999999,1.26,722.855,fee schedule,""
"ANTIHEM FACT (BDD-RFVIII,MOR) 500 UNITS IV KIT",0250,J7185,58394002303,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,1625.00 ,1137.50 ,Aetna,"AETNA",2.62,191,fee schedule,999999999,1.26,1137.5,fee schedule,""
"ANTIHEM FACT (BDD-RFVIII,MOR) 1000 UNITS IV KIT",0250,J7185,58394001401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,6.72 ,4.70 ,Aetna,"AETNA",2.62,191,fee schedule,999999999,1.26,4.704,fee schedule,""
"ANTIHEM FACT (BDD-RFVIII,MOR) 2000 UNITS IV KIT",0250,J7185,58394001501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,4956.69 ,3469.68 ,Aetna,"AETNA",2.62,191,fee schedule,999999999,1.26,3469.683,fee schedule,""
"ALBUMIN HUMAN 25 % IV SOLN",0250,P9047,44206025105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,198.30 ,138.81 ,Aetna,"AETNA",101.38,191,fee schedule,999999999,45.9,138.81,fee schedule,""
"ALBUMIN HUMAN 5 % IV SOLN",0250,P9045,44206031025,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ML,,198.00 ,138.60 ,Aetna,"AETNA",101.38,191,fee schedule,999999999,47.49,138.6,fee schedule,""
"AMIODARONE HCL 150 MG/3ML IV SOLN",0250,J0282,00143987525,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,6.12 ,4.28 ,Aetna,"AETNA",1.15,191,fee schedule,999999999,0.45,4.284,fee schedule,""
"ALDESLEUKIN 22000000 UNITS IV SOLR",0250,J9015,76310002201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,16238.04 ,11366.63 ,Aetna,"AETNA",12723.96,191,fee schedule,999999999,4871.412,12723.9616,fee schedule,""
"ALPROSTADIL 500 MCG/ML INJ SOLN",0250,J0270,00009316906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,mcg,,758.69 ,531.08 ,Aetna,"AETNA",23.55,191,fee schedule,999999999,10.05,531.083,fee schedule,""
"ALPROSTADIL 500 MCG/ML INJ SOLN",0250,J0270,00009316901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,mcg,,588.53 ,411.97 ,Aetna,"AETNA",23.55,191,fee schedule,999999999,10.05,531.083,fee schedule,""
"ALTEPLASE 100 MG IV SOLR",0250,J2997,50242008527,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,24582.06 ,17207.44 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,17207.442,fee schedule,""
"ALTEPLASE 50 MG IV SOLR",0250,J2997,50242004406,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12291.03 ,8603.72 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,8603.721,fee schedule,""
"ALTEPLASE 50 MG IV SOLR",0250,J2997,50242004413,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12291.03 ,8603.72 ,Aetna,"AETNA",169.65,191,fee schedule,999999999,88.03,8603.721,fee schedule,""
"ALUM & MAG HYDROXIDE-SIMETH 400-400-40 MG/5ML PO SUSP",0250,A9270,00121176230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.39 ,3.77 ,Aetna,"AETNA",2.43,45,percent of total billed charges,999999999,0.03087,3.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"MIDAZOLAM HCL 50 MG/10ML INJ SOLN",0250,J2250,23155060132,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,28.49 ,19.94 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,19.943,fee schedule,""
"MIDAZOLAM HCL 50 MG/10ML INJ SOLN",0250,J2250,23155060142,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,28.49 ,19.94 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.14,19.943,fee schedule,""
"ROMIPLOSTIM 250 MCG SC SOLR",0250,J2796,55513022101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,mcg,,7483.35 ,5238.35 ,Aetna,"AETNA",184.09,191,fee schedule,999999999,89,5238.345,fee schedule,""
"ROMIPLOSTIM 500 MCG SC SOLR",0250,J2796,55513022201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,mcg,,14966.70 ,10476.69 ,Aetna,"AETNA",184.09,191,fee schedule,999999999,89,10476.69,fee schedule,""
"AMINOCAPROIC ACID 500 MG PO TABS",0250,A9270,69238163703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,26.88 ,18.82 ,Aetna,"AETNA",12.10,45,percent of total billed charges,999999999,0.03087,18.816,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMIODARONE HCL 200 MG PO TABS",0250,A9270,00904699361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMLODIPINE BESYLATE 10 MG PO TABS",0250,A9270,00904637161,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMLODIPINE BESYLATE 2.5 MG PO TABS",0250,A9270,68382012116,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMLODIPINE BESYLATE 5 MG PO TABS",0250,A9270,68382012205,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMLODIPINE BESYLATE 5 MG PO TABS",0250,A9270,68180072009,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5ML PO SUSR",0250,A9270,60432006575,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,139.50 ,97.65 ,Aetna,"AETNA",62.78,45,percent of total billed charges,999999999,0.03087,97.65,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS",0250,A9270,47781017601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G INJ SOLR",0250,J0295,44567021010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.5,GR,,8.93 ,6.25 ,Aetna,"AETNA",4.05,191,fee schedule,999999999,1.769,6.251,fee schedule,""
"AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G INJ SOLR",0250,J0295,44567021110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.5,GR,,20.53 ,14.37 ,Aetna,"AETNA",4.05,191,fee schedule,999999999,1.769,14.371,fee schedule,""
"ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR",0250,J7197,13533060320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,22.12 ,15.48 ,Aetna,"AETNA",7.14,191,fee schedule,999999999,3.35,15.484,fee schedule,""
"MITOXANTRONE HCL 25 MG/12.5ML IV CONC",0250,J9293,61703034365,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,1003.94 ,702.76 ,Aetna,"AETNA",81.50,191,fee schedule,999999999,29.06,702.758,fee schedule,""
"APRACLONIDINE HCL 1 % OP SOLN",0250,,00065066010,RC,,NDC,FACILITY,OUTPATIENT,0.5,UN  ,,77.00 ,53.90 ,Aetna,"AETNA",34.65,45,percent of total billed charges,999999999,23.1,53.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARGININE HCL (DIAGNOSTIC) 10 % IV SOLN",0250,,00009043601,RC,,NDC,FACILITY,OUTPATIENT,300,ML,,234.00 ,163.80 ,Aetna,"AETNA",105.30,45,percent of total billed charges,999999999,70.2,163.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ARTIFICIAL TEARS OP OINTMENT",0250,A9270,70000051301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,3.5,GR,,29.40 ,20.58 ,Aetna,"AETNA",13.23,45,percent of total billed charges,999999999,0.03087,20.58,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SORBITOL 70 % SOLN",0250,A9270,46287050030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,16.17 ,11.32 ,Aetna,"AETNA",7.28,45,percent of total billed charges,999999999,0.03087,11.319,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ASPIRIN-ACETAMINOPHEN-CAFFEINE 250-250-65 MG PO TABS",0250,A9270,00536132601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AZATHIOPRINE 50 MG PO TABS",0250,J7500,68084022901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.89,191,fee schedule,999999999,1.5,13.7,fee schedule,""
"AZATHIOPRINE 50 MG PO TABS",0250,J7500,68084022911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,5.00 ,3.50 ,Aetna,"AETNA",4.89,191,fee schedule,999999999,1.5,13.7,fee schedule,""
"AZTREONAM 1 G INJ SOLR",0250,J0457,63323040120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,66.37 ,46.46 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.52,46.459,fee schedule,""
"AZTREONAM 2 G INJ SOLR",0250,J0457,63323040220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,271.01 ,189.71 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.52,209.377,fee schedule,""
"AZTREONAM 2 G INJ SOLR",0250,J0457,63323040201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,299.11 ,209.38 ,Aetna,"AETNA",4.93,191,fee schedule,999999999,2.52,209.377,fee schedule,""
"BENAZEPRIL HCL 10 MG PO TABS",0250,A9270,51079014520,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.62 ,5.33 ,Aetna,"AETNA",3.43,45,percent of total billed charges,999999999,0.03087,5.334,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENAZEPRIL HCL 10 MG PO TABS",0250,A9270,51079014501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,5.334,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENAZEPRIL HCL 20 MG PO TABS",0250,A9270,50268011115,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENAZEPRIL HCL 20 MG PO TABS",0250,A9270,50268011111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENAZEPRIL HCL 5 MG PO TABS",0250,A9270,50268010915,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENAZEPRIL HCL 5 MG PO TABS",0250,A9270,50268010911,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN",0250,J3030,55150017301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,6,ME,,24.28 ,17.00 ,Aetna,"AETNA",143.82,191,fee schedule,999999999,7.284,143.823,fee schedule,""
"BENZTROPINE MESYLATE 1 MG/ML INJ SOLN",0250,J0515,17478001202,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,54.48 ,38.14 ,Aetna,"AETNA",31.42,191,fee schedule,999999999,14.6,38.136,fee schedule,""
"BENZTROPINE MESYLATE 1 MG/ML INJ SOLN",0250,J0515,1747801212,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,54.48 ,38.14 ,Aetna,"AETNA",31.42,191,fee schedule,999999999,14.6,38.136,fee schedule,""
"BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML INJ SUSP",0250,J0702,00517072001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,6,ME,,41.45 ,29.02 ,Aetna,"AETNA",13.16,191,fee schedule,999999999,6.41,29.015,fee schedule,""
"BETAXOLOL HCL 0.5 % OP SOLN",0250,A9270,61314024501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ML,,284.82 ,199.37 ,Aetna,"AETNA",128.17,45,percent of total billed charges,999999999,0.03087,199.374,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RUFINAMIDE 200 MG PO TABS",0250,A9270,00054042523,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,52.46 ,36.72 ,Aetna,"AETNA",23.61,45,percent of total billed charges,999999999,0.03087,36.722,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN",0250,A9270,99999001299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN",0250,A9270,00536134480,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,23.80 ,16.66 ,Aetna,"AETNA",10.71,45,percent of total billed charges,999999999,0.03087,16.66,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BISMUTH SUBSALICYLATE 262 MG PO CHEW",0250,A9270,00904720546,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROCURONIUM BROMIDE 50 MG/5ML IV SOLN",0250,,55150022505,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,12.99 ,9.09 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.897,9.093,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROCURONIUM BROMIDE 100 MG/10ML IV SOLN",0250,,00781322092,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,44.835,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ROCURONIUM BROMIDE 100 MG/10ML IV SOLN",0250,,39822420005,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,64.05 ,44.84 ,Aetna,"AETNA",28.82,45,percent of total billed charges,999999999,8.4,44.835,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BLEOMYCIN SULFATE 15 UNITS INJ SOLR",0250,J9040,63323013610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,160.74 ,112.52 ,Aetna,"AETNA",44.16,191,fee schedule,999999999,21.024,112.518,fee schedule,""
"BLEOMYCIN SULFATE 15 UNITS INJ SOLR",0250,J9040,71288010610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,158.76 ,111.13 ,Aetna,"AETNA",44.16,191,fee schedule,999999999,21.024,112.518,fee schedule,""
"BLEOMYCIN SULFATE 15 UNITS INJ SOLR",0250,J9040,61703033218,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,UN  ,,150.06 ,105.04 ,Aetna,"AETNA",44.16,191,fee schedule,999999999,21.024,112.518,fee schedule,""
"BROMOCRIPTINE MESYLATE 5 MG PO CAPS",0250,A9270,68382011006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,29.30 ,20.51 ,Aetna,"AETNA",13.19,45,percent of total billed charges,999999999,0.03087,20.51,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BROMOCRIPTINE MESYLATE 2.5 MG PO TABS",0250,A9270,00574010603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.71 ,6.80 ,Aetna,"AETNA",4.37,45,percent of total billed charges,999999999,0.03087,6.797,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUMETANIDE 0.25 MG/ML INJ SOLN",0250,J1939,72205010207,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",1.20,191,fee schedule,999999999,0.665,3.5,fee schedule,""
"BUMETANIDE 0.5 MG PO TABS",0250,A9270,50268013011,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.41 ,5.19 ,Aetna,"AETNA",3.33,45,percent of total billed charges,999999999,0.03087,5.306,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUMETANIDE 0.5 MG PO TABS",0250,A9270,50268013015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.58 ,5.31 ,Aetna,"AETNA",3.41,45,percent of total billed charges,999999999,0.03087,5.306,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUMETANIDE 1 MG PO TABS",0250,A9270,00904701604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.22 ,3.65 ,Aetna,"AETNA",2.35,45,percent of total billed charges,999999999,0.03087,3.654,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN",0250,J0665,00409361301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,7.46 ,5.22 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,5.222,fee schedule,""
"BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN",0250,J0665,00409361311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,6.78 ,4.75 ,Aetna,"AETNA",0.04,191,fee schedule,999999999,0.014,5.222,fee schedule,""
"BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 INJ SOLN",0250,,00409175550,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPRENORPHINE HCL 0.3 MG/ML INJ SOLN",0250,J0592,12496075701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ME,,85.88 ,60.12 ,Aetna,"AETNA",7.51,191,fee schedule,999999999,4.03,60.116,fee schedule,""
"BUPROPION HCL 100 MG PO TABS",0250,A9270,00781106401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.69 ,5.38 ,Aetna,"AETNA",3.46,45,percent of total billed charges,999999999,0.03087,5.383,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUPROPION HCL 75 MG PO TABS",0250,A9270,60505015801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUSPIRONE HCL 10 MG PO TABS",0250,A9270,00093005401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUSPIRONE HCL 5 MG PO TABS",0250,A9270,00378114001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUSULFAN 2 MG PO TABS",0250,J8510,76388071325,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2,ME,,130.48 ,91.34 ,Aetna,"AETNA",314.84,191,fee schedule,999999999,39.144,314.8444,fee schedule,""
"BUTAMBEN-TETRACAINE-BENZOCAINE 2-2-14 % EX AERO",0250,A9270,10223020104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,GR,,323.76 ,226.63 ,Aetna,"AETNA",145.69,45,percent of total billed charges,999999999,0.03087,226.632,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BUTORPHANOL TARTRATE 1 MG/ML INJ SOLN",0250,J0595,00409162301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,20.46 ,14.32 ,Aetna,"AETNA",6.84,191,fee schedule,999999999,2.54,14.322,fee schedule,""
"BUTORPHANOL TARTRATE 2 MG/ML INJ SOLN",0250,J0595,00409162601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,12.56 ,8.79 ,Aetna,"AETNA",6.84,191,fee schedule,999999999,2.54,8.792,fee schedule,""
"CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN",0250,J0630,24201040002,RC,HCPCS,NDC,FACILITY,OUTPATIENT,400,UN  ,,3000.00 ,2100.00 ,Aetna,"AETNA",2104.32,191,fee schedule,999999999,900,2104.3234,fee schedule,""
"CALCITRIOL 0.25 MCG PO CAPS",0250,A9270,64380072306,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCITRIOL 0.5 MCG PO CAPS",0250,A9270,69452020820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SM OATMEAL BATH 100 % EX PACK",0250,A9270,08137003640,RC,HCPCS,NDC,FACILITY,OUTPATIENT,8,UN  ,,5.74 ,4.02 ,Aetna,"AETNA",2.58,45,percent of total billed charges,999999999,0.03087,4.018,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CALCIUM CARBONATE ANTACID 500 MG PO CHEW",0250,A9270,48433010601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAMPHOR-PHENOL 10.8-4.7 % EX GEL",0250,A9270,00024021201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,6.5,GR,,21.61 ,15.13 ,Aetna,"AETNA",9.72,45,percent of total billed charges,999999999,0.03087,15.127,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAPTOPRIL 12.5 MG PO TABS",0250,A9270,00904504561,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.73 ,5.41 ,Aetna,"AETNA",3.48,45,percent of total billed charges,999999999,0.03087,5.411,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CAPTOPRIL 25 MG PO TABS",0250,A9270,27241016101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FEBUXOSTAT 40 MG PO TABS",0250,A9270,43547029503,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.97 ,4.18 ,Aetna,"AETNA",2.69,45,percent of total billed charges,999999999,0.03087,4.179,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBIDOPA-LEVODOPA 10-100 MG PO TABS",0250,A9270,50228045701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBIDOPA-LEVODOPA 25-100 MG PO TABS",0250,A9270,60687066101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBIDOPA-LEVODOPA 25-250 MG PO TABS",0250,A9270,60687083601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBIDOPA-LEVODOPA 25-250 MG PO TABS",0250,A9270,60687083611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN",0250,,43598069811,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,847.56 ,593.29 ,Aetna,"AETNA",381.40,45,percent of total billed charges,999999999,147.126,593.292,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN",0250,,43598069858,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,490.42 ,343.29 ,Aetna,"AETNA",220.69,45,percent of total billed charges,999999999,147.126,593.292,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"METHOTREXATE SODIUM (PF) 25 MG/ML INJ SOLN",0250,J9260,00703367501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,27.09 ,18.96 ,Aetna,"AETNA",4.91,191,fee schedule,999999999,2.33,144.816,fee schedule,""
"METHOTREXATE SODIUM (PF) 25 MG/ML INJ SOLN",0250,J9260,16729027730,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,27.51 ,19.26 ,Aetna,"AETNA",4.91,191,fee schedule,999999999,2.33,144.816,fee schedule,""
"METHOTREXATE SODIUM (PF) 25 MG/ML INJ SOLN",0250,J9260,16729027735,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,206.88 ,144.82 ,Aetna,"AETNA",4.91,191,fee schedule,999999999,2.33,144.816,fee schedule,""
"METHOTREXATE SODIUM (PF) 25 MG/ML INJ SOLN",0250,J9260,00703367881,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ME,,191.52 ,134.06 ,Aetna,"AETNA",4.91,191,fee schedule,999999999,2.33,144.816,fee schedule,""
"CYTARABINE (PF) 20 MG/ML INJ SOLN",0250,J9100,61703030558,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,30.24 ,21.17 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.92,22.862,fee schedule,""
"CYTARABINE (PF) 20 MG/ML INJ SOLN",0250,J9100,61703030538,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,32.66 ,22.86 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.92,22.862,fee schedule,""
"DEGARELIX ACETATE 80 MG SC SOLR",0250,J9155,55566830301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1478.05 ,1034.64 ,Aetna,"AETNA",8.31,191,fee schedule,999999999,4.08,1034.635,fee schedule,""
"CONIVAPTAN HCL IN DEXTROSE 20-5 MG/100ML-% IV SOLN",0250,,66220016010,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,900,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACOSAMIDE 50 MG PO TABS",0250,A9270,00904724468,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.87 ,5.51 ,Aetna,"AETNA",3.54,45,percent of total billed charges,999999999,0.03087,5.509,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACOSAMIDE 100 MG PO TABS",0250,A9270,62332017260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACOSAMIDE 200 MG/20ML IV SOLN",0250,C9254,70710135901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,57.48 ,40.24 ,Aetna,"AETNA",0.46,191,fee schedule,999999999,0.3,40.236,fee schedule,""
"LACOSAMIDE 200 MG/20ML IV SOLN",0250,C9254,70710135906,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,54.78 ,38.35 ,Aetna,"AETNA",0.46,191,fee schedule,999999999,0.3,40.236,fee schedule,""
"CEFOTETAN DISODIUM 1 G INJ SOLR",0250,,00143967010,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,33.71 ,23.60 ,Aetna,"AETNA",15.17,45,percent of total billed charges,999999999,10.113,23.597,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFOTETAN DISODIUM 2 G INJ SOLR",0250,,63323038620,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,144.36 ,101.05 ,Aetna,"AETNA",64.96,45,percent of total billed charges,999999999,43.308,101.052,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D3 (CHOLECALCIFEROL) 125 MCG (5000 UT) PO TABS",0250,A9270,07610017840,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFTAZIDIME 1 G INJ SOLR",0250,J0713,25021012720,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,18.77 ,13.14 ,Aetna,"AETNA",3.17,191,fee schedule,999999999,1.694,13.139,fee schedule,""
"PROMETHAZINE HCL 6.25 MG/5ML PO SOLN",0250,Q0169,00121092716,RC,HCPCS,NDC,FACILITY,OUTPATIENT,12.5,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.19,191,fee schedule,999999999,0.08,3.5,fee schedule,""
"CEFTAZIDIME 6 G INJ SOLR",0250,J0713,44567023706,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,162.40 ,113.68 ,Aetna,"AETNA",3.17,191,fee schedule,999999999,1.694,113.68,fee schedule,""
"FACTOR IX COMPLEX 1500 UNITS IV SOLR",0250,J7194,68516320302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,F2,,5.00 ,3.50 ,Aetna,"AETNA",3.08,191,fee schedule,999999999,1.5,3.5,fee schedule,""
"AMIODARONE HCL 450 MG/9ML IV SOLN",0250,J0282,63323061609,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,10.21 ,7.15 ,Aetna,"AETNA",1.15,191,fee schedule,999999999,0.45,7.147,fee schedule,""
"AMIODARONE HCL 900 MG/18ML IV SOLN",0250,J0282,67457015318,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,ME,,75.17 ,52.62 ,Aetna,"AETNA",1.15,191,fee schedule,999999999,0.45,52.619,fee schedule,""
"CEFTRIAXONE SODIUM 1 G INJ SOLR",0250,J0696,60505614800,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.76 ,4.03 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,4.032,fee schedule,""
"CEFTRIAXONE SODIUM 1 G INJ SOLR",0250,J0696,60505614804,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.76 ,4.03 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,4.032,fee schedule,""
"CEFTRIAXONE SODIUM 2 G INJ SOLR",0250,J0696,60505614900,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,10.01 ,7.01 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,7.007,fee schedule,""
"CEFTRIAXONE SODIUM 2 G INJ SOLR",0250,J0696,60505614904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,10.01 ,7.01 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,7.007,fee schedule,""
"CEFTRIAXONE SODIUM 250 MG INJ SOLR",0250,J0696,00409733701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.44 ,3.81 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,13.237,fee schedule,""
"CEFTRIAXONE SODIUM 250 MG INJ SOLR",0250,J0696,60505075004,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,18.91 ,13.24 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,13.237,fee schedule,""
"CEFTRIAXONE SODIUM 250 MG INJ SOLR",0250,J0696,00409733711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.44 ,3.81 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,13.237,fee schedule,""
"CEFTRIAXONE SODIUM 500 MG INJ SOLR",0250,J0696,60505615201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,5.00 ,3.50 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,3.5,fee schedule,""
"CEFTRIAXONE SODIUM 10 G IV SOLR",0250,J0696,60505615005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,54.39 ,38.07 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,38.073,fee schedule,""
"CEFTRIAXONE SODIUM IN DEXTROSE 40 MG/ML IV SOLN",0250,J0696,00338500341,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,70.50 ,49.35 ,Aetna,"AETNA",0.86,191,fee schedule,999999999,0.47,49.35,fee schedule,""
"CEFUROXIME AXETIL 250 MG PO TABS",0250,A9270,65862069920,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEFUROXIME AXETIL 500 MG PO TABS",0250,A9270,65862070020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEPHALEXIN 250 MG PO CAPS",0250,A9270,60687015201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEPHALEXIN 250 MG PO CAPS",0250,A9270,60687015211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEPHALEXIN 500 MG PO CAPS",0250,A9270,60687016311,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEPHALEXIN 500 MG PO CAPS",0250,A9270,60687016301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CEPHALEXIN 250 MG/5ML PO SUSR",0250,A9270,67877054588,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CETIRIZINE HCL 10 MG PO TABS",0250,A9270,00904671761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 25 MG/5ML IV SOLN",0250,J3490,00641601301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,7.87 ,5.51 ,Aetna,"AETNA",3.54,45,percent of total billed charges,999999999,0,5.509,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 25 MG/5ML IV SOLN",0250,J3490,00641601310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,ME,,7.87 ,5.51 ,Aetna,"AETNA",3.54,45,percent of total billed charges,999999999,0,5.509,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DILTIAZEM HCL 125 MG/25ML IV SOLN",0250,,00641601510,RC,,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLORAMBUCIL 2 MG PO TABS",0250,A9270,00173063535,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,26.55 ,18.59 ,Aetna,"AETNA",11.95,45,percent of total billed charges,999999999,0.03087,18.585,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TOBRAMYCIN SULFATE 1.2 GM/30ML INJ SOLN",0250,J3260,67457042800,RC,HCPCS,NDC,FACILITY,OUTPATIENT,80,ME,,156.78 ,109.75 ,Aetna,"AETNA",4.87,191,fee schedule,999999999,2.6,109.746,fee schedule,""
"CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN",0250,A9270,00904703580,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLOROTHIAZIDE 250 MG/5ML PO SUSP",0250,A9270,65649031112,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,8.13 ,5.69 ,Aetna,"AETNA",3.66,45,percent of total billed charges,999999999,0.03087,5.691,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CHLOROTHIAZIDE SODIUM 500 MG IV SOLR",0250,J1205,63323065820,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,147.12 ,102.98 ,Aetna,"AETNA",167.62,191,fee schedule,999999999,44.136,167.6216,fee schedule,""
"PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS PO CPEP",0250,A9270,00032120601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.55 ,9.49 ,Aetna,"AETNA",6.10,45,percent of total billed charges,999999999,0.03087,9.485,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS PO CPEP",0250,A9270,00032263601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FLUOROURACIL 5 GM/100ML IV SOLN",0250,J9190,63323011769,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,88.20 ,61.74 ,Aetna,"AETNA",5.63,191,fee schedule,999999999,1.83,61.74,fee schedule,""
"CICLOPIROX OLAMINE 0.77 % EX CREA",0250,A9270,45802013835,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,87.57 ,61.30 ,Aetna,"AETNA",39.41,45,percent of total billed charges,999999999,0.03087,61.299,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CICLOPIROX OLAMINE 0.77 % EX CREA",0250,A9270,68462029717,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,85.77 ,60.04 ,Aetna,"AETNA",38.60,45,percent of total billed charges,999999999,0.03087,61.299,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUFENTANIL CITRATE 100 MCG/2ML IV SOLN",0250,,17478005002,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,47.95 ,33.57 ,Aetna,"AETNA",21.58,45,percent of total billed charges,999999999,14.385,33.565,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SUFENTANIL CITRATE 250 MCG/5ML IV SOLN",0250,,00641611201,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,95.04 ,66.53 ,Aetna,"AETNA",42.77,45,percent of total billed charges,999999999,28.512,66.528,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FERUMOXYTOL 510 MG/17ML IV SOLN",0250,Q0139,59338077501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3334.13 ,2333.89 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.357,2333.891,fee schedule,""
"DRONEDARONE HCL 400 MG PO TABS",0250,A9270,00024414260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,72.82 ,50.97 ,Aetna,"AETNA",32.77,45,percent of total billed charges,999999999,0.03087,50.974,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CIPROFLOXACIN HCL 0.3 % OP SOLN",0250,,61314065605,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,123.84 ,86.69 ,Aetna,"AETNA",55.73,45,percent of total billed charges,999999999,37.152,86.688,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PRASUGREL HCL 10 MG PO TABS",0250,A9270,67877060530,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,7.66 ,5.36 ,Aetna,"AETNA",3.45,45,percent of total billed charges,999999999,0.03087,5.362,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLARITHROMYCIN 250 MG PO TABS",0250,A9270,00781196160,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLARITHROMYCIN 500 MG PO TABS",0250,A9270,00781196260,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TECHNETIUM TC 99M MEDRONATE IV KIT",0250,,17156043804,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,154.37 ,108.06 ,Aetna,"AETNA",69.47,45,percent of total billed charges,999999999,46.311,108.059,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN",0250,J0736,00781328909,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,24.50 ,17.15 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,17.15,fee schedule,""
"CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN",0250,J0736,00781328991,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,24.50 ,17.15 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,17.15,fee schedule,""
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN",0250,J0736,00781329009,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,28.70 ,20.09 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,20.09,fee schedule,""
"CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN",0250,J0736,00781329091,RC,HCPCS,NDC,FACILITY,OUTPATIENT,300,ME,,28.70 ,20.09 ,Aetna,"AETNA",4.34,191,fee schedule,999999999,1.61,20.09,fee schedule,""
"CLOBETASOL PROPIONATE 0.05 % EX CREA",0250,A9270,21922001604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,32.55 ,22.79 ,Aetna,"AETNA",14.65,45,percent of total billed charges,999999999,0.03087,22.785,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOBETASOL PROPIONATE 0.05 % EX OINT",0250,A9270,51672125901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,15,GR,,24.68 ,17.28 ,Aetna,"AETNA",11.11,45,percent of total billed charges,999999999,0.03087,17.276,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOMIPRAMINE HCL 25 MG PO CAPS",0250,A9270,51672401105,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONAZEPAM 0.5 MG PO TABS",0250,A9270,43547040610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONAZEPAM 1 MG PO TABS",0250,A9270,60687055501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLONAZEPAM 1 MG PO TABS",0250,A9270,60687055511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VIGABATRIN 500 MG PO PACK",0250,A9270,43598069750,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,1531.50 ,1072.05 ,Aetna,"AETNA",689.18,45,percent of total billed charges,999999999,0.03087,1072.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LEVONORGESTREL 1.5 MG PO TABS",0250,A9270,68180085211,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,0.03087,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOTRIMAZOLE 10 MG MT TROC",0250,A9270,00054814622,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOZAPINE 100 MG PO TABS",0250,A9270,00904708761,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLOZAPINE 25 MG PO TABS",0250,A9270,00904708961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OXALIPLATIN 50 MG/10ML IV SOLN",0250,J9263,70860020110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,300.06 ,210.04 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.06,210.042,fee schedule,""
"OXALIPLATIN 100 MG/20ML IV SOLN",0250,J9263,00703398601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,377.88 ,264.52 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.06,420.084,fee schedule,""
"OXALIPLATIN 100 MG/20ML IV SOLN",0250,J9263,61703036322,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,507.00 ,354.90 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.06,420.084,fee schedule,""
"OXALIPLATIN 100 MG/20ML IV SOLN",0250,J9263,25021023320,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,162.00 ,113.40 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.06,420.084,fee schedule,""
"OXALIPLATIN 100 MG/20ML IV SOLN",0250,J9263,70860020120,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,600.12 ,420.08 ,Aetna,"AETNA",0.13,191,fee schedule,999999999,0.06,420.084,fee schedule,""
"SEVELAMER CARBONATE 0.8 G PO PACK",0250,,00955105201,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,61.56 ,43.09 ,Aetna,"AETNA",27.70,45,percent of total billed charges,999999999,3.903,43.092,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 0.8 G PO PACK",0250,,00955105290,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,61.56 ,43.09 ,Aetna,"AETNA",27.70,45,percent of total billed charges,999999999,3.903,43.092,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 0.8 G PO PACK",0250,,43598047890,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.01 ,9.11 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.903,43.092,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 0.8 G PO PACK",0250,,43598047801,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.01 ,9.11 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.903,43.092,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 2.4 G PO PACK",0250,,43598047990,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.83 ,9.68 ,Aetna,"AETNA",6.22,45,percent of total billed charges,999999999,4.149,9.681,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SEVELAMER CARBONATE 2.4 G PO PACK",0250,,43598047901,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,13.83 ,9.68 ,Aetna,"AETNA",6.22,45,percent of total billed charges,999999999,4.149,9.681,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COLLAGENASE 250 UNIT/GM EX OINT",0250,A9270,50484001030,RC,HCPCS,NDC,FACILITY,OUTPATIENT,30,GR,,1279.20 ,895.44 ,Aetna,"AETNA",575.64,45,percent of total billed charges,999999999,0.03087,895.44,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"COSYNTROPIN 0.25 MG INJ SOLR",0250,J0834,00781344095,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.25,ME,,181.57 ,127.10 ,Aetna,"AETNA",54.61,191,fee schedule,999999999,27.114,127.099,fee schedule,""
"OSELTAMIVIR 15 MG/ML ORAL SUSP",0250,A9270,99999734499,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,145.00 ,101.50 ,Aetna,"AETNA",65.25,45,percent of total billed charges,999999999,0.03087,101.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUANFACINE HCL ER 1 MG PO TB24",0250,A9270,60505392701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GUANFACINE HCL ER 2 MG PO TB24",0250,A9270,60505392801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN",0250,,00065035902,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,199.62 ,139.73 ,Aetna,"AETNA",89.83,45,percent of total billed charges,999999999,59.886,247.842,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN",0250,,00065035905,RC,,NDC,FACILITY,OUTPATIENT,2,ML,,354.06 ,247.84 ,Aetna,"AETNA",159.33,45,percent of total billed charges,999999999,59.886,247.842,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYCLOSPORINE 50 MG/ML IV SOLN",0250,J7516,00078010961,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,301.83 ,211.28 ,Aetna,"AETNA",89.64,191,fee schedule,999999999,39.11,262.29,fee schedule,""
"CYCLOSPORINE 50 MG/ML IV SOLN",0250,J7516,00078010901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ME,,374.70 ,262.29 ,Aetna,"AETNA",89.64,191,fee schedule,999999999,39.11,262.29,fee schedule,""
"CYCLOSPORINE 100 MG PO CAPS",0250,J7502,60505013400,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,50.44 ,35.31 ,Aetna,"AETNA",4.39,191,fee schedule,999999999,1.76,35.308,fee schedule,""
"CYCLOSPORINE 25 MG PO CAPS",0250,J7515,60505013300,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,13.01 ,9.11 ,Aetna,"AETNA",1.76,191,fee schedule,999999999,0.66,9.107,fee schedule,""
"CYCLOSPORINE 100 MG/ML PO SOLN",0250,J7502,00078011022,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,60.00 ,42.00 ,Aetna,"AETNA",4.39,191,fee schedule,999999999,1.76,42,fee schedule,""
"PALIPERIDONE ER 1.5 MG PO TB24",0250,A9270,47335074483,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,26.36 ,18.45 ,Aetna,"AETNA",11.86,45,percent of total billed charges,999999999,7.908,18.452,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DANAZOL 50 MG PO CAPS",0250,A9270,00527139201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,14.04 ,9.83 ,Aetna,"AETNA",6.32,45,percent of total billed charges,999999999,0.03087,9.828,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DANTROLENE SODIUM 20 MG IV SOLR",0250,,42023012306,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,300.75 ,210.53 ,Aetna,"AETNA",135.34,45,percent of total billed charges,999999999,90.225,210.525,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DANTROLENE SODIUM 25 MG PO CAPS",0250,A9270,00115441101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEFEROXAMINE MESYLATE 500 MG INJ SOLR",0250,J0895,63323059710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ME,,72.30 ,50.61 ,Aetna,"AETNA",17.23,191,fee schedule,999999999,7.93,50.61,fee schedule,""
"DEMECLOCYCLINE HCL 300 MG PO TABS",0250,A9270,42806014448,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,12.28 ,8.60 ,Aetna,"AETNA",5.53,45,percent of total billed charges,999999999,0.03087,8.596,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ABOBOTULINUMTOXINA 500 UNITS IM SOLR",0250,J0586,15054050001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,5,UN  ,,3000.00 ,2100.00 ,Aetna,"AETNA",16.58,191,fee schedule,999999999,8.22,2100,fee schedule,""
"PRALATREXATE 20 MG/ML IV SOLN",0250,J9307,48818000101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,20362.56 ,14253.79 ,Aetna,"AETNA",571.62,191,fee schedule,999999999,289.141,14253.792,fee schedule,""
"TELAVANCIN HCL 750 MG IV SOLR",0250,J3095,62847000101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2303.05 ,1612.14 ,Aetna,"AETNA",13.62,191,fee schedule,999999999,6.69,1612.135,fee schedule,""
"DESONIDE 0.05 % EX OINT",0250,A9270,45802042337,RC,HCPCS,NDC,FACILITY,OUTPATIENT,60,GR,,431.64 ,302.15 ,Aetna,"AETNA",194.24,45,percent of total billed charges,999999999,0.03087,302.148,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OFATUMUMAB 100 MG/5ML IV CONC",0250,J9302,00173082133,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,2316.08 ,1621.26 ,Aetna,"AETNA",138.28,191,fee schedule,999999999,60.34,1621.256,fee schedule,""
"OPIUM 10 MG/ML (1%) PO TINC",0250,A9270,62559015304,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,7.55 ,5.29 ,Aetna,"AETNA",3.40,45,percent of total billed charges,999999999,0.03087,7.392,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OPIUM 10 MG/ML (1%) PO TINC",0250,A9270,99999007399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,10.56 ,7.39 ,Aetna,"AETNA",4.75,45,percent of total billed charges,999999999,0.03087,7.392,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"C1 ESTERASE INHIBITOR (HUMAN) 500 UNITS IV KIT",0250,J0597,63833082502,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,UN  ,,19134.24 ,13393.97 ,Aetna,"AETNA",123.06,191,fee schedule,999999999,60.78,13393.968,fee schedule,""
"KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN",0250,,00338080304,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN",0250,,99999056799,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KCL IN DEXTROSE-NACL 40-5-0.9 MEQ/L-%-% IV SOLN",0250,,00338080704,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN",0250,,00338067104,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KCL IN DEXTROSE-NACL 30-5-0.45 MEQ/L-%-% IV SOLN",0250,,00338067304,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN",0250,,00338067504,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS",0250,A9270,64380073706,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENDAMUSTINE HCL 25 MG IV SOLR",0250,J9033,63459039008,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",15.97,191,fee schedule,999999999,9.07,2100,fee schedule,""
"RIFAMPIN PO SUSP 25 MG/ML",0250,A9270,99999737399,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,38.88 ,27.22 ,Aetna,"AETNA",17.50,45,percent of total billed charges,999999999,0.03087,27.216,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"IBUTILIDE FUMARATE 1 MG/10ML IV SOLN",0250,J1742,67457036610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,1864.40 ,1305.08 ,Aetna,"AETNA",683.70,191,fee schedule,999999999,270,1305.08,fee schedule,""
"IBUTILIDE FUMARATE 1 MG/10ML IV SOLN",0250,J1742,00009379401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,900.00 ,630.00 ,Aetna,"AETNA",683.70,191,fee schedule,999999999,270,1305.08,fee schedule,""
"DIGOXIN 0.1 MG/ML INJ SOLN",0250,J1160,70515026210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.5,ME,,705.91 ,494.14 ,Aetna,"AETNA",17.30,191,fee schedule,999999999,9.408,494.137,fee schedule,""
"DIHYDROERGOTAMINE MESYLATE 1 MG/ML INJ SOLN",0250,J1110,00143927301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,134.07 ,93.85 ,Aetna,"AETNA",70.90,191,fee schedule,999999999,40.221,93.849,fee schedule,""
"DIHYDROERGOTAMINE MESYLATE 1 MG/ML INJ SOLN",0250,J1110,00143927310,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,134.07 ,93.85 ,Aetna,"AETNA",70.90,191,fee schedule,999999999,40.221,93.849,fee schedule,""
"SILDENAFIL CITRATE 10 MG/12.5ML IV SOLN",0250,J3490,55150016613,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,716.48 ,501.54 ,Aetna,"AETNA",322.42,45,percent of total billed charges,999999999,0,501.536,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"OLANZAPINE PAMOATE 300 MG IM SUSR",0250,J2358,00002763611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ME,,3000.00 ,2100.00 ,Aetna,"AETNA",5.58,191,fee schedule,999999999,2.917,2100,fee schedule,""
"DIMERCAPROL 100 MG/ML IM SOLN",0250,J0470,17478052603,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,900.00 ,630.00 ,Aetna,"AETNA",122.58,191,fee schedule,999999999,54.55,630,fee schedule,""
"DIMETHYL SULFOXIDE 50 % IS SOLN",0250,J1212,67457017750,RC,HCPCS,NDC,FACILITY,OUTPATIENT,50,ML,,2647.60 ,1853.32 ,Aetna,"AETNA",1299.11,191,fee schedule,999999999,636.54,1853.32,fee schedule,""
"DINOPROSTONE 0.5 MG/3GM VA GEL",0250,A9270,00009335901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RITONAVIR 100 MG PO TABS",0250,A9270,65862068730,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.95 ,6.97 ,Aetna,"AETNA",4.48,45,percent of total billed charges,999999999,0.03087,6.965,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENZONATATE 100 MG PO CAPS",0250,A9270,42806071401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DIPYRIDAMOLE 5 MG/ML IV SOLN",0250,J1245,00641256944,RC,HCPCS,NDC,FACILITY,OUTPATIENT,10,ME,,102.96 ,72.07 ,Aetna,"AETNA",7.14,191,fee schedule,999999999,3.69,72.072,fee schedule,""
"DOXAZOSIN MESYLATE 1 MG PO TABS",0250,A9270,00832035611,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXAZOSIN MESYLATE 2 MG PO TABS",0250,A9270,68084085111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DOXAZOSIN MESYLATE 2 MG PO TABS",0250,A9270,68084085101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ACETAMINOPHEN 80 MG PO CHEW",0250,A9270,00904579146,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,4.00 ,2.80 ,Aetna,"AETNA",1.80,45,percent of total billed charges,999999999,0.03087,2.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PANCRELIPASE FEEDING TUBE SOLUTION",0250,,99999738099,RC,,NDC,FACILITY,OUTPATIENT,20,ML,,67.20 ,47.04 ,Aetna,"AETNA",30.24,45,percent of total billed charges,999999999,20.16,47.04,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TAMSULOSIN HCL 0.4 MG PO CAPS",0250,A9270,68084029901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DRONABINOL 2.5 MG PO CAPS",0250,Q0167,67877075360,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,9.74 ,6.82 ,Aetna,"AETNA",1.60,191,fee schedule,999999999,0.62,6.818,fee schedule,""
"DRONABINOL 5 MG PO CAPS",0250,Q0167,60687038621,RC,HCPCS,NDC,FACILITY,OUTPATIENT,2.5,ME,,31.49 ,22.04 ,Aetna,"AETNA",1.60,191,fee schedule,999999999,0.62,22.043,fee schedule,""
"ENALAPRIL MALEATE 10 MG PO TABS",0250,A9270,23155077201,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRIL MALEATE 2.5 MG PO TABS",0250,A9270,23155070401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRIL MALEATE 5 MG PO TABS",0250,A9270,23155070501,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRILAT 1.25 MG/ML IV INJ",0250,J3490,00143978610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,ME,,10.70 ,7.49 ,Aetna,"AETNA",4.82,45,percent of total billed charges,999999999,0,8.918,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRILAT 1.25 MG/ML IV INJ",0250,J3490,00143978710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,ME,,12.74 ,8.92 ,Aetna,"AETNA",5.73,45,percent of total billed charges,999999999,0,8.918,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRILAT 1.25 MG/ML IV INJ",0250,J3490,00143978701,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,ME,,12.74 ,8.92 ,Aetna,"AETNA",5.73,45,percent of total billed charges,999999999,0,8.918,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ENALAPRILAT 1.25 MG/ML IV INJ",0250,J3490,00143978601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1.25,ME,,10.70 ,7.49 ,Aetna,"AETNA",4.82,45,percent of total billed charges,999999999,0,8.918,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,00409427902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,63323049257,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,10.25 ,7.18 ,Aetna,"AETNA",4.61,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,63323049227,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.39 ,10.77 ,Aetna,"AETNA",6.93,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,00409427916,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,63323049204,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,15.39 ,10.77 ,Aetna,"AETNA",6.93,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 1 % INJ SOLN",0250,J3490,63323049209,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,10.25 ,7.18 ,Aetna,"AETNA",4.61,45,percent of total billed charges,999999999,0,10.773,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 2 % INJ SOLN",0250,,00143959401,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,5.068,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LIDOCAINE HCL (PF) 2 % INJ SOLN",0250,,00143959425,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,7.24 ,5.07 ,Aetna,"AETNA",3.26,45,percent of total billed charges,999999999,2.172,5.068,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"EPOETIN ALFA 10000 UNIT/ML INJ SOLN",0250,Q4081,55513014401,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,894.41 ,626.09 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,630,fee schedule,""
"EPOETIN ALFA 10000 UNIT/ML INJ SOLN",0250,Q4081,55513014410,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,900.00 ,630.00 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,630,fee schedule,""
"EPOETIN ALFA 2000 UNIT/ML INJ SOLN",0250,Q4081,55513012601,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,178.88 ,125.22 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,134.428,fee schedule,""
"EPOETIN ALFA 2000 UNIT/ML INJ SOLN",0250,Q4081,55513012610,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,192.04 ,134.43 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,134.428,fee schedule,""
"EPOETIN ALFA 3000 UNIT/ML INJ SOLN",0250,Q4081,59676030300,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,408.14 ,285.70 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,300.209,fee schedule,""
"EPOETIN ALFA 3000 UNIT/ML INJ SOLN",0250,Q4081,59676030301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,428.87 ,300.21 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,300.209,fee schedule,""
"EPOETIN ALFA 4000 UNIT/ML INJ SOLN",0250,Q4081,55513014801,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,357.77 ,250.44 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,268.87,fee schedule,""
"EPOETIN ALFA 4000 UNIT/ML INJ SOLN",0250,Q4081,55513014810,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,UN  ,,384.10 ,268.87 ,Aetna,"AETNA",1.59,191,fee schedule,999999999,0.69,268.87,fee schedule,""
"ESTERIFIED ESTROGENS 0.625 MG PO TABS",0250,A9270,61570007301,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,18.63 ,13.04 ,Aetna,"AETNA",8.38,45,percent of total billed charges,999999999,0.03087,13.041,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTRADIOL 1 MG PO TABS",0250,A9270,70954056510,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTROGENS CONJUGATED 25 MG INJ SOLR",0250,J1410,00046074905,RC,HCPCS,NDC,FACILITY,OUTPATIENT,25,ME,,1713.45 ,1199.42 ,Aetna,"AETNA",711.23,191,fee schedule,999999999,355.49,1199.415,fee schedule,""
"ESTROGENS CONJUGATED 0.3 MG PO TABS",0250,A9270,00046110081,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,45.01 ,31.51 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,0.03087,31.507,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ESTROGENS CONJUGATED 0.625 MG PO TABS",0250,A9270,00046110281,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,45.01 ,31.51 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,0.03087,31.507,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETHACRYNATE SODIUM 50 MG IV SOLR",0250,,25010021027,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,14007.45 ,9805.22 ,Aetna,"AETNA",6303.35,45,percent of total billed charges,999999999,4202.235,9805.215,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENZTROPINE MESYLATE 0.5 MG PO TABS",0250,A9270,68084038101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENZTROPINE MESYLATE 0.5 MG PO TABS",0250,A9270,68084038111,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETHACRYNIC ACID 25 MG PO TABS",0250,A9270,68180015901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,9.30 ,6.51 ,Aetna,"AETNA",4.19,45,percent of total billed charges,999999999,0.03087,6.51,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETHAMBUTOL HCL 400 MG PO TABS",0250,A9270,68084028001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,0.03087,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETHANOLAMINE OLEATE 5 % IV SOLN",0250,J1430,67871479006,RC,HCPCS,NDC,FACILITY,OUTPATIENT,100,ME,,1677.38 ,1174.17 ,Aetna,"AETNA",906.18,191,fee schedule,999999999,456.86,1174.166,fee schedule,""
"PEGINTERFERON ALFA-2B 80 MCG/0.5ML SC KIT",0250,,00085129101,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,2982.32 ,2087.62 ,Aetna,"AETNA",1342.04,45,percent of total billed charges,999999999,894.696,2087.624,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"BENZTROPINE MESYLATE 1 MG PO TABS",0250,A9270,00904679061,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RIFAXIMIN 550 MG PO TABS",0250,A9270,65649030302,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,294.21 ,205.95 ,Aetna,"AETNA",132.39,45,percent of total billed charges,999999999,0.03087,205.947,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETODOLAC 200 MG PO CAPS",0250,A9270,60505003901,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"ETODOLAC 300 MG PO CAPS",0250,A9270,60505004001,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,0.03087,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE FLUSH 0.9 % IV SOLN",0250,,08290306546,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KIT SURGIFLO W/OUT THROMBIN - (6EA/CA)",0250,,,RC,,,FACILITY,OUTPATIENT,,,,615.88 ,431.12 ,Aetna,"AETNA",277.15,45,percent of total billed charges,999999999,184.761,431.116,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"KIT SURGIFLO W/OUT THROMBIN - (6EA/CA)",0250,,,RC,,,FACILITY,OUTPATIENT,,,,615.87 ,431.11 ,Aetna,"AETNA",277.14,45,percent of total billed charges,999999999,184.761,431.116,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG OMNIPAQUE 300MG/ML PER ML",0254,Q9967,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1.00 ,0.70 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,0.7,fee schedule,""
"INDOCYANINE GREEN 25 MG IV SOLR",0254,,70100042402,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,814.99 ,570.49 ,Aetna,"AETNA",366.75,45,percent of total billed charges,999999999,244.497,570.493,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDIGOTINDISULFONATE SODIUM 8 MG/ML IV SOLN",0254,,81284031500,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,1862.20 ,1303.54 ,Aetna,"AETNA",837.99,45,percent of total billed charges,999999999,558.66,1303.54,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INDIGOTINDISULFONATE SODIUM 8 MG/ML IV SOLN",0254,,81284031505,RC,,NDC,FACILITY,OUTPATIENT,5,ML,,1862.20 ,1303.54 ,Aetna,"AETNA",837.99,45,percent of total billed charges,999999999,558.66,1303.54,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"GADOTERIDOL 279.3 MG/ML IV SOLN",0255,A9579,00270111101,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,76.20 ,53.34 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,106.68,fee schedule,""
"GADOTERIDOL 279.3 MG/ML IV SOLN",0255,A9579,00270111102,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,114.30 ,80.01 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,106.68,fee schedule,""
"GADOTERIDOL 279.3 MG/ML IV SOLN",0255,A9579,00270111103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,152.40 ,106.68 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,106.68,fee schedule,""
"GADOTERIDOL 279.3 MG/ML IV SOLN",0255,A9579,00270111104,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,44.45 ,31.12 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,106.68,fee schedule,""
"IOHEXOL 180 MG/ML INJ SOLN",0255,Q9965,00407141110,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,144.12 ,100.88 ,Aetna,"AETNA",1.95,191,fee schedule,999999999,0.78,100.884,fee schedule,""
"IOHEXOL 350 MG/ML IV SOLN",0255,Q9967,00407141489,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,55.65 ,38.96 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,131.04,fee schedule,""
"IOHEXOL 350 MG/ML IV SOLN",0255,Q9967,00407141494,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,187.20 ,131.04 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,131.04,fee schedule,""
"IOHEXOL 350 MG/ML IV SOLN",0255,Q9967,00407141491,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,93.00 ,65.10 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,131.04,fee schedule,""
"IOHEXOL 350 MG/ML IV SOLN",0255,Q9967,99999056299,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,47.60 ,33.32 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,131.04,fee schedule,""
"IOPAMIDOL 76 % IV SOLN",0255,Q9967,00270131604,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,70.00 ,49.00 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,49,fee schedule,""
"GADOBUTROL 1 MMOL/ML IV SOLN",0255,A9585,50419032511,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ML,,373.50 ,261.45 ,Aetna,"AETNA",0.67,191,fee schedule,999999999,0.32,522.9,fee schedule,""
"GADOBUTROL 1 MMOL/ML IV SOLN",0255,A9585,50419032512,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ML,,498.00 ,348.60 ,Aetna,"AETNA",0.67,191,fee schedule,999999999,0.32,522.9,fee schedule,""
"GADOBUTROL 1 MMOL/ML IV SOLN",0255,A9585,50419032513,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ML,,747.00 ,522.90 ,Aetna,"AETNA",0.67,191,fee schedule,999999999,0.32,522.9,fee schedule,""
"GADOBUTROL 1 MMOL/ML IV SOLN",0255,A9585,50419032537,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ML,,99.60 ,69.72 ,Aetna,"AETNA",0.67,191,fee schedule,999999999,0.32,522.9,fee schedule,""
"GADOBUTROL 1 MMOL/ML IV SOLN",0255,A9585,50419032507,RC,HCPCS,NDC,FACILITY,OUTPATIENT,0.1,ML,,99.60 ,69.72 ,Aetna,"AETNA",0.67,191,fee schedule,999999999,0.32,522.9,fee schedule,""
"IOHEXOL 300 MG/ML INJ SOLN",0255,Q9967,00407141361,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,51.10 ,35.77 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,58.8,fee schedule,""
"IOHEXOL 300 MG/ML INJ SOLN",0255,Q9967,00407141363,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,84.00 ,58.80 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,58.8,fee schedule,""
"IOHEXOL 240 MG/ML INJ SOLN",0255,Q9966,00407141233,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,75.00 ,52.50 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,115.92,fee schedule,""
"IOHEXOL 240 MG/ML INJ SOLN",0255,Q9966,00407141230,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,49.00 ,34.30 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,115.92,fee schedule,""
"IOHEXOL 240 MG/ML INJ SOLN",0255,Q9966,00407141210,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,156.72 ,109.70 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,115.92,fee schedule,""
"IOHEXOL 240 MG/ML INJ SOLN",0255,Q9966,00407141220,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,165.60 ,115.92 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,115.92,fee schedule,""
"GADODIAMIDE 287 MG/ML IV SOLN",0255,A9579,00407069005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,161.55 ,113.09 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,402.528,fee schedule,""
"GADODIAMIDE 287 MG/ML IV SOLN",0255,A9579,00407069010,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,317.64 ,222.35 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,402.528,fee schedule,""
"GADODIAMIDE 287 MG/ML IV SOLN",0255,A9579,00407069015,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,465.57 ,325.90 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,402.528,fee schedule,""
"GADODIAMIDE 287 MG/ML IV SOLN",0255,A9579,00407069020,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,575.04 ,402.53 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,402.528,fee schedule,""
"IODIXANOL 270 MG/ML IV SOLN",0255,Q9966,00407222219,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,288.00 ,201.60 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,207.9,fee schedule,""
"IODIXANOL 270 MG/ML IV SOLN",0255,Q9966,00407222217,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,197.40 ,138.18 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,207.9,fee schedule,""
"IODIXANOL 270 MG/ML IV SOLN",0255,Q9966,65219038103,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,297.00 ,207.90 ,Aetna,"AETNA",0.74,191,fee schedule,999999999,0.32,207.9,fee schedule,""
"IOPAMIDOL 61 % IV SOLN",0255,Q9967,00270131535,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,56.70 ,39.69 ,Aetna,"AETNA",0.27,191,fee schedule,999999999,0.118,39.69,fee schedule,""
"GADODIAMIDE 287 MG/ML INJ SOLN",0255,A9579,00407069012,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,115.08 ,80.56 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,143.556,fee schedule,""
"GADODIAMIDE 287 MG/ML INJ SOLN",0255,A9579,00407069022,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,205.08 ,143.56 ,Aetna,"AETNA",2.88,191,fee schedule,999999999,1.518,143.556,fee schedule,""
"GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN",0255,A9578,00270516413,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,88.92 ,62.24 ,Aetna,"AETNA",3.30,191,fee schedule,999999999,1.772,124.488,fee schedule,""
"GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN",0255,A9578,00270516415,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,177.84 ,124.49 ,Aetna,"AETNA",3.30,191,fee schedule,999999999,1.772,124.488,fee schedule,""
"PERFLUTREN PROTEIN A MICROSPH IV SUSP",0255,Q9956,00407270703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,509.99 ,356.99 ,Aetna,"AETNA",84.96,191,fee schedule,999999999,30.5,356.993,fee schedule,""
"PERFLUTREN PROTEIN A MICROSPH IV SUSP",0255,Q9956,00407270718,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,491.99 ,344.39 ,Aetna,"AETNA",84.96,191,fee schedule,999999999,30.5,356.993,fee schedule,""
"GADOXETATE DISODIUM 0.25 MOL/L IV SOLN",0255,A9581,50419032005,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1,ML,,851.76 ,596.23 ,Aetna,"AETNA",28.19,191,fee schedule,999999999,14.73,596.232,fee schedule,""
"BARIUM SULFATE 700 MG PO TABS",0255,,10361077831,RC,,NDC,FACILITY,OUTPATIENT,1,UN  ,,5.68 ,3.98 ,Aetna,"AETNA",2.56,45,percent of total billed charges,999999999,1.704,3.976,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RINGERS IV SOLN",0258,,99999704499,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RINGERS IV SOLN",0258,,00338010504,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 12.5%-0.45% NACL INFUSION",0258,,99999023099,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYSTEINE HCL 50 MG/ML IV SOLN",0258,,51754100701,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,562.38 ,393.67 ,Aetna,"AETNA",253.07,45,percent of total billed charges,999999999,168.714,393.666,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CYSTEINE HCL 50 MG/ML IV SOLN",0258,,51754100703,RC,,NDC,FACILITY,OUTPATIENT,10,ML,,562.38 ,393.67 ,Aetna,"AETNA",253.07,45,percent of total billed charges,999999999,168.714,393.666,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINISOL SF 15 % IV SOLN",0258,,00338050206,RC,,NDC,FACILITY,OUTPATIENT,2000,ML,,288.00 ,201.60 ,Aetna,"AETNA",129.60,45,percent of total billed charges,999999999,86.4,201.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN",0258,,00338114703,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,198.00 ,138.60 ,Aetna,"AETNA",89.10,45,percent of total billed charges,999999999,59.4,138.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10 % IV SOLN",0258,,00338002302,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,15.75 ,11.03 ,Aetna,"AETNA",7.09,45,percent of total billed charges,999999999,4.725,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10 % IV SOLN",0258,,00338002303,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,17.50 ,12.25 ,Aetna,"AETNA",7.88,45,percent of total billed charges,999999999,4.725,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10 % IV SOLN",0258,,00338002304,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,4.725,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 20 % IV SOLN",0258,,00990793519,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,31.50 ,22.05 ,Aetna,"AETNA",14.18,45,percent of total billed charges,999999999,9.45,22.05,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 5 % IV SOLN",0258,J7060,00338001702,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,12.25 ,8.58 ,Aetna,"AETNA",3.44,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"DEXTROSE 5 % IV SOLN",0258,J7060,00338001703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,10.50 ,7.35 ,Aetna,"AETNA",3.44,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"DEXTROSE 5 % IV SOLN",0258,J7070,00338001704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.88,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"DEXTROSE 5 % IV SOLN",0258,J7060,00338001710,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,11.73 ,8.21 ,Aetna,"AETNA",3.44,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"DEXTROSE 5 % IV SOLN",0258,J7060,00338001711,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,11.20 ,7.84 ,Aetna,"AETNA",3.44,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"DEXTROSE 5 % IV SOLN",0258,J7060,00338001718,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,11.20 ,7.84 ,Aetna,"AETNA",3.44,191,fee schedule,999999999,1.63,9.8,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7050,00338004902,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.50 ,7.35 ,Aetna,"AETNA",1.24,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7040,00338004903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.50 ,7.35 ,Aetna,"AETNA",2.48,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338004904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338004910,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,12.25 ,8.58 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338004918,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,11.20 ,7.84 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338004931,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.15 ,7.11 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338004938,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 0.9 % IV SOLN",0258,J7030,00338055318,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,23.10 ,16.17 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.64,16.17,fee schedule,""
"SODIUM CHLORIDE 3% INFUSION (PICU)",0258,,00338005403,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,17.50 ,12.25 ,Aetna,"AETNA",7.88,45,percent of total billed charges,999999999,5.25,12.25,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10% BOLUS (NICU/PEDS)",0258,,00338002302,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,15.75 ,11.03 ,Aetna,"AETNA",7.09,45,percent of total billed charges,999999999,4.725,11.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 3 % IV BOLUS (PICU)",0258,,00338005403,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,17.50 ,12.25 ,Aetna,"AETNA",7.88,45,percent of total billed charges,999999999,5.25,12.25,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"FREAMINE III 10 % IV SOLN",0258,,00264901055,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PREMASOL 10 % IV SOLN",0258,,00338113004,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,198.00 ,138.60 ,Aetna,"AETNA",89.10,45,percent of total billed charges,999999999,59.4,138.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 12.5%-WATER IV SOLN",0258,,99999642099,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TPN NEONATAL BASE SOLUTION 500 ML",0258,,99999111899,RC,,NDC,FACILITY,OUTPATIENT,800,ML,,132.00 ,92.40 ,Aetna,"AETNA",59.40,45,percent of total billed charges,999999999,39.6,92.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TPN ICN STOCK SOLN 10% 250 ML",0258,,99999689099,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,82.50 ,57.75 ,Aetna,"AETNA",37.13,45,percent of total billed charges,999999999,24.75,57.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10% BOLUS",0258,,00338002302,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,15.75 ,11.03 ,Aetna,"AETNA",7.09,45,percent of total billed charges,999999999,2.625,11.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 10% BOLUS",0258,,00338002303,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,8.75 ,6.13 ,Aetna,"AETNA",3.94,45,percent of total billed charges,999999999,2.625,11.025,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"RENOWN COLD NORMAL SALINE (FOR CODE CHILL)",0258,J7050,99999COLD99,RC,HCPCS,NDC,FACILITY,OUTPATIENT,250,ML,,14.00 ,9.80 ,Aetna,"AETNA",1.24,191,fee schedule,999999999,0.64,9.8,fee schedule,""
"SODIUM CHLORIDE 0.9 % BOLUS (RWN)",0258,J7030,00338004904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,2.54,9.8,fee schedule,""
"TPN ICN STOCK SOLN 7.5% 250 ML",0258,,99999034299,RC,,NDC,FACILITY,OUTPATIENT,250,ML,,82.50 ,57.75 ,Aetna,"AETNA",37.13,45,percent of total billed charges,999999999,24.75,57.75,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTATED RINGERS BOLUS INFUSION",0258,J7120,00338011703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.64,191,fee schedule,999999999,1.2,7.35,fee schedule,""
"LACTATED RINGERS BOLUS INFUSION",0258,J7120,00338011704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,4.00 ,2.80 ,Aetna,"AETNA",4.64,191,fee schedule,999999999,1.2,7.35,fee schedule,""
"PLASMA-LYTE A BOLUS INFUSION",0258,,00338022104,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.73,45,percent of total billed charges,999999999,3.15,7.35,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN",0258,,00409792403,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,31.50 ,22.05 ,Aetna,"AETNA",14.18,45,percent of total billed charges,999999999,4.2,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN",0258,,00409792409,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,4.2,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN",0258,,99999703499,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,31.50 ,22.05 ,Aetna,"AETNA",14.18,45,percent of total billed charges,999999999,4.2,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.225 % IV SOLN",0258,,99999703599,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"AMINOSYN II 15 % IV SOLN",0258,,00409717117,RC,,NDC,FACILITY,OUTPATIENT,2000,ML,,192.00 ,134.40 ,Aetna,"AETNA",86.40,45,percent of total billed charges,999999999,57.6,134.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTATED RINGERS IV SOLN",0258,J7120,00338011703,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.64,191,fee schedule,999999999,1.2,7.35,fee schedule,""
"LACTATED RINGERS IV SOLN",0258,J7120,00338011704,RC,HCPCS,NDC,FACILITY,OUTPATIENT,1000,ML,,4.00 ,2.80 ,Aetna,"AETNA",4.64,191,fee schedule,999999999,1.2,7.35,fee schedule,""
"PLASMA-LYTE 148 IV SOLN",0258,,00338017904,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,39.06 ,27.34 ,Aetna,"AETNA",17.58,45,percent of total billed charges,999999999,11.718,27.342,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"PLASMA-LYTE A IV SOLN",0258,,00338022104,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,10.50 ,7.35 ,Aetna,"AETNA",4.73,45,percent of total billed charges,999999999,3.15,7.35,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.45 % IV SOLN",0258,,00409773037,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,12.60 ,8.82 ,Aetna,"AETNA",5.67,45,percent of total billed charges,999999999,3.78,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.45 % IV SOLN",0258,,00338004303,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,3.78,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 0.45 % IV SOLN",0258,,00338004304,RC,,NDC,FACILITY,OUTPATIENT,100,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,3.78,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"SODIUM CHLORIDE 3 % IV SOLN",0258,,00338005403,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,17.50 ,12.25 ,Aetna,"AETNA",7.88,45,percent of total billed charges,999999999,5.25,12.25,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"INTRAOP DEXTROSE 2.5% - LACT RINGERS IV SOLN",0258,,99999704399,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"TRAVASOL 10 % IV SOLN",0258,,00338064406,RC,,NDC,FACILITY,OUTPATIENT,2000,ML,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTRAN 40 IN D5W 10 % IV SOLN",0258,,00409741803,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,144.00 ,100.80 ,Aetna,"AETNA",64.80,45,percent of total billed charges,999999999,34.2,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTRAN 40 IN D5W 10 % IV SOLN",0258,,00409741813,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,114.00 ,79.80 ,Aetna,"AETNA",51.30,45,percent of total billed charges,999999999,34.2,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 5 % IN LACTATED RINGERS IV SOLN",0258,,00338012503,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE 5 % IN LACTATED RINGERS IV SOLN",0258,,00338012504,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN",0258,,00264762200,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,63.00 ,44.10 ,Aetna,"AETNA",28.35,45,percent of total billed charges,999999999,18.9,44.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN",0258,,00338007704,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN",0258,,00338008504,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,7.00 ,4.90 ,Aetna,"AETNA",3.15,45,percent of total billed charges,999999999,2.1,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN",0258,,63323086974,RC,,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,2.1,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN",0258,J7042,00338008903,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,4.00 ,2.80 ,Aetna,"AETNA",2.16,191,fee schedule,999999999,0.96,9.8,fee schedule,""
"DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN",0258,J7030,00338008904,RC,HCPCS,NDC,FACILITY,OUTPATIENT,500,ML,,14.00 ,9.80 ,Aetna,"AETNA",4.99,191,fee schedule,999999999,0.96,9.8,fee schedule,""
"HCHG SUBCUTANEOUS INFUSION EACH ADDL HR",0260,96370,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",48.37,308.7,fee schedule,999999999,13.53,800,fee schedule,""
"HCHG INFUSION EXTENDED IV W/PUMP HOME",0260,C8957,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,2279.00 ,1595.30 ,Aetna,"AETNA",1162.84,308.7,fee schedule,999999999,559,1595.3,fee schedule,""
"HCHG INF THERAPY-HYDRATION 31-60MIN",0260,96360,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",97.89,308.7,fee schedule,999999999,35.22,1024.1,fee schedule,""
"HCHG INF THERAPY-HYDRATION EA ADDHR",0260,96361,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",37.23,308.7,fee schedule,999999999,13.29,800,fee schedule,""
"HCHG INF THERAPY-TH/DIAG-CONC < 1HR",0260,96368,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,146.00 ,102.20 ,Aetna,"AETNA",59.49,308.7,fee schedule,999999999,18.05,800,fee schedule,""
"HCHG INF THERAPY-TH/DIAG-INIT < 1HR",0260,96365,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",189.39,308.7,fee schedule,999999999,61.38,1024.1,fee schedule,""
"HCHG INF THERAPY/DIAG ADD HR",0260,96366,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",61.49,308.7,fee schedule,999999999,16.42,800,fee schedule,""
"HCHG INF THERAPY-TH/DIAG-SEQ < 1HR",0260,96367,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,443.00 ,310.10 ,Aetna,"AETNA",85.76,308.7,fee schedule,999999999,26.69,800,fee schedule,""
"HCHG TX-PRO-DX IV PUSH SNGL/INITIAL",0260,96374,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",110.89,308.7,fee schedule,999999999,40.41,1024.1,fee schedule,""
"HCHG INJECTION-DIAG/THERAP-SQ/IM",0260,96372,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,443.00 ,310.10 ,Aetna,"AETNA",43.31,308.7,fee schedule,999999999,14.68,800,fee schedule,""
"HCHG TX-PRO-DX IV PUSH NEW DRG",0260,96375,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",46.34,308.7,fee schedule,999999999,16.4,800,fee schedule,""
"HCHG TX-PRO-DX IV PSH SAME DRG",0260,96376,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,208.00 ,145.60 ,Aetna,"AETNA",32.48,308.7,fee schedule,999999999,12.76,800,fee schedule,""
"HCHG THERA PROPH DX INJ INTRA ARTERIAL",0260,96373,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",56.46,308.7,fee schedule,999999999,17.08,1024.1,fee schedule,""
"HCHG INJECTION-DIAG/THERAP-SQ/IM",0260,96372,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,443.00 ,310.10 ,Aetna,"AETNA",43.31,308.7,fee schedule,999999999,14.68,800,fee schedule,""
"HCHG INF THERAPY-HYDRATION 31-60MIN",0260,96360,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",97.89,308.7,fee schedule,999999999,35.22,1024.1,fee schedule,""
"HCHG INF THERAPY-HYDRATION EA ADDHR",0260,96361,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",37.23,308.7,fee schedule,999999999,13.29,800,fee schedule,""
"HCHG TX-PRO-DX IV PUSH NEW DRUG",0260,96375,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,286.00 ,200.20 ,Aetna,"AETNA",46.34,308.7,fee schedule,999999999,16.4,800,fee schedule,""
"HCHG TX-PRO-DX IV PUSH SNGL/INITIAL",0260,96374,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1463.00 ,1024.10 ,Aetna,"AETNA",110.89,308.7,fee schedule,999999999,40.41,1024.1,fee schedule,""
"HCHG INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT",0260,96372,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,443.00 ,310.10 ,Aetna,"AETNA",43.31,308.7,fee schedule,999999999,14.68,800,fee schedule,""
"HCHG PROLACT+4 10ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,375.00 ,262.50 ,Aetna,"AETNA",168.75,45,percent of total billed charges,999999999,112.5,262.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT+4 20ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,750.00 ,525.00 ,Aetna,"AETNA",337.50,45,percent of total billed charges,999999999,225,525,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT+6 30ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,938.00 ,656.60 ,Aetna,"AETNA",422.10,45,percent of total billed charges,999999999,281.4,656.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT+8 40ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,1250.00 ,875.00 ,Aetna,"AETNA",562.50,45,percent of total billed charges,999999999,375,875,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT+10 50ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,1563.00 ,1094.10 ,Aetna,"AETNA",703.35,45,percent of total billed charges,999999999,468.9,1094.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT RTF 24 100ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT RTF 26 100ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,1050.00 ,735.00 ,Aetna,"AETNA",472.50,45,percent of total billed charges,999999999,315,735,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT RTF 28 100ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,1350.00 ,945.00 ,Aetna,"AETNA",607.50,45,percent of total billed charges,999999999,405,945,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROLACT CR 10ML",0270,,,RC,,,FACILITY,OUTPATIENT,,,,240.00 ,168.00 ,Aetna,"AETNA",108.00,45,percent of total billed charges,999999999,72,168,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYPOTHERMIA WRAP VEST LARGE",0271,,,RC,,,FACILITY,OUTPATIENT,,,,304.00 ,212.80 ,Aetna,"AETNA",136.80,45,percent of total billed charges,999999999,91.2,212.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ABDOMINAL BINDER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,22.5,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ACE WRAP 2TO4",0271,,,RC,,,FACILITY,OUTPATIENT,,,,7.00 ,4.90 ,Aetna,"AETNA",3.15,45,percent of total billed charges,999999999,2.1,4.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ACE WRAP 4TO6",0271,,,RC,,,FACILITY,OUTPATIENT,,,,92.00 ,64.40 ,Aetna,"AETNA",41.40,45,percent of total billed charges,999999999,27.6,64.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARM ELEVATOR BAG",0271,,,RC,,,FACILITY,OUTPATIENT,,,,105.00 ,73.50 ,Aetna,"AETNA",47.25,45,percent of total billed charges,999999999,31.5,73.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE ACE 2 OR 3",0271,,,RC,,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE ACE 4 OR 6",0271,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELASTIC BANDAGE 4IN",0271,,,RC,,,FACILITY,OUTPATIENT,,,,30.00 ,21.00 ,Aetna,"AETNA",13.50,45,percent of total billed charges,999999999,9,21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELASTIC BANDAGE 6IN",0271,,,RC,,,FACILITY,OUTPATIENT,,,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,10.5,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EYE PATCH",0271,,,RC,,,FACILITY,OUTPATIENT,,,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FOX EYE SHIELD",0271,,,RC,,,FACILITY,OUTPATIENT,,,,13.00 ,9.10 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.9,9.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GLOVES ISOTONER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,53.00 ,37.10 ,Aetna,"AETNA",23.85,45,percent of total billed charges,999999999,15.9,37.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYPAFIX RET DRST 18SQ PC",0271,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG IRRIGATION SYSTEM",0271,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NITRO SET VENT 2ND TUB",0271,,,RC,,,FACILITY,OUTPATIENT,,,,17.00 ,11.90 ,Aetna,"AETNA",7.65,45,percent of total billed charges,999999999,5.1,11.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BARRRIER MOISTURE 2.5 OZ.",0271,A6250,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,40.00 ,28.00 ,Aetna,"AETNA",0.12,308.7,fee schedule,999999999,0.12348,28,fee schedule,""
"HCHG R 2 PADS",0271,,,RC,,,FACILITY,OUTPATIENT,,,,198.00 ,138.60 ,Aetna,"AETNA",89.10,45,percent of total billed charges,999999999,59.4,138.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPAS SPLINT ORTHO",0271,,,RC,,,FACILITY,OUTPATIENT,,,,144.00 ,100.80 ,Aetna,"AETNA",64.80,45,percent of total billed charges,999999999,43.2,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPEAKING VALVE ADAPTER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,6.00 ,4.20 ,Aetna,"AETNA",2.70,45,percent of total billed charges,999999999,1.8,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT MTRLS/SQ.INCH",0271,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUPPLEMENTAL NURSING SYSTEM",0271,,,RC,,,FACILITY,OUTPATIENT,,,,155.00 ,108.50 ,Aetna,"AETNA",69.75,45,percent of total billed charges,999999999,46.5,108.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG VISCOPASTE UNNAS TYPE",0271,A6456,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXT PANELS 5.5 BACK SUPP",0271,,,RC,,,FACILITY,OUTPATIENT,,,,217.00 ,151.90 ,Aetna,"AETNA",97.65,45,percent of total billed charges,999999999,65.1,151.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXT PANELS 3.5 BACK SUPP",0271,,,RC,,,FACILITY,OUTPATIENT,,,,193.00 ,135.10 ,Aetna,"AETNA",86.85,45,percent of total billed charges,999999999,57.9,135.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PEDS AP PADS",0271,,,RC,,,FACILITY,OUTPATIENT,,,,492.00 ,344.40 ,Aetna,"AETNA",221.40,45,percent of total billed charges,999999999,147.6,344.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARMREST, CRADLE FOAM",0271,,,RC,,,FACILITY,OUTPATIENT,,,,67.00 ,46.90 ,Aetna,"AETNA",30.15,45,percent of total billed charges,999999999,20.1,46.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, LEG LARGE",0271,A4358,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,19.00 ,13.30 ,Aetna,"AETNA",8.55,45,percent of total billed charges,999999999,6.46,13.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, LEG MEDIUM",0271,A4358,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.33,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, URINARY DRAINAGE (CLOSED)",0271,,,RC,,,FACILITY,OUTPATIENT,,,,29.00 ,20.30 ,Aetna,"AETNA",13.05,45,percent of total billed charges,999999999,8.7,20.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ACE ELASTIC 2",0271,,,RC,,,FACILITY,OUTPATIENT,,,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,3,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ACE ELASTIC 3",0271,,,RC,,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ADH ELASTIC",0271,,,RC,,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.2,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ELASTIC 4",0271,,,RC,,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ELASTIC 6",0271,,,RC,,,FACILITY,OUTPATIENT,,,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,3.3,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, ESMARK 6",0271,,,RC,,,FACILITY,OUTPATIENT,,,,34.00 ,23.80 ,Aetna,"AETNA",15.30,45,percent of total billed charges,999999999,10.2,23.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BINDER, 4-PANEL MED/LG",0271,,,RC,,,FACILITY,OUTPATIENT,,,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,22.5,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BITE BLOCK, ECT",0271,,,RC,,,FACILITY,OUTPATIENT,,,,19.00 ,13.30 ,Aetna,"AETNA",8.55,45,percent of total billed charges,999999999,5.7,13.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, CLIPPER NEURO",0271,,,RC,,,FACILITY,OUTPATIENT,,,,81.00 ,56.70 ,Aetna,"AETNA",36.45,45,percent of total billed charges,999999999,24.3,56.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CRUTCHES",0271,E0114,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,73.00 ,51.10 ,Aetna,"AETNA",151.51,308.7,fee schedule,999999999,21.9,151.50996,fee schedule,""
"HCHG ELECTRODE, ACROMIOPLASTY",0271,,,RC,,,FACILITY,OUTPATIENT,,,,228.00 ,159.60 ,Aetna,"AETNA",102.60,45,percent of total billed charges,999999999,68.4,159.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EYE SHIELD W/GARTER (FOX)",0271,,,RC,,,FACILITY,OUTPATIENT,,,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,3.3,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HUMID-VENT, DISP",0271,,,RC,,,FACILITY,OUTPATIENT,,,,13.00 ,9.10 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.9,9.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG JAW BRA",0271,,,RC,,,FACILITY,OUTPATIENT,,,,104.00 ,72.80 ,Aetna,"AETNA",46.80,45,percent of total billed charges,999999999,31.2,72.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, BEACH CHAIR POSITIONER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,220.00 ,154.00 ,Aetna,"AETNA",99.00,45,percent of total billed charges,999999999,66,154,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MARKERS, PASSIVE REFLECTIVE",0271,,,RC,,,FACILITY,OUTPATIENT,,,,525.00 ,367.50 ,Aetna,"AETNA",236.25,45,percent of total billed charges,999999999,157.5,367.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG OSTOMY, SUREFIT LOOP ROD 2 3/4",0271,,,RC,,,FACILITY,OUTPATIENT,,,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, JACKSON TABLE",0271,,,RC,,,FACILITY,OUTPATIENT,,,,165.00 ,115.50 ,Aetna,"AETNA",74.25,45,percent of total billed charges,999999999,49.5,115.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PAD, UNIVERSAL KNEE POSITIONER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PILLOW, ABDUCTION HIP SM",0271,,,RC,,,FACILITY,OUTPATIENT,,,,100.00 ,70.00 ,Aetna,"AETNA",45.00,45,percent of total billed charges,999999999,30,70,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PILLOW, ABDUCTION SHOULDER MED",0271,,,RC,,,FACILITY,OUTPATIENT,,,,471.00 ,329.70 ,Aetna,"AETNA",211.95,45,percent of total billed charges,999999999,141.3,329.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SLING, ARM",0271,A4565,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SLING, ULTRASLING",0271,A4565,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,353.00 ,247.10 ,Aetna,"AETNA",158.85,45,percent of total billed charges,999999999,105.9,247.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPHERE, REFLECTIVE MARKER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,141.00 ,98.70 ,Aetna,"AETNA",63.45,45,percent of total billed charges,999999999,42.3,98.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT, NASAL DENVER",0271,,,RC,,,FACILITY,OUTPATIENT,,,,162.00 ,113.40 ,Aetna,"AETNA",72.90,45,percent of total billed charges,999999999,48.6,113.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT, NASAL DOYLE AIRWAY",0271,,,RC,,,FACILITY,OUTPATIENT,,,,204.00 ,142.80 ,Aetna,"AETNA",91.80,45,percent of total billed charges,999999999,61.2,142.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT, NASAL EXTERNAL",0271,,,RC,,,FACILITY,OUTPATIENT,,,,183.00 ,128.10 ,Aetna,"AETNA",82.35,45,percent of total billed charges,999999999,54.9,128.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT ORTHO GLASS 3IN X15FT",0271,,,RC,,,FACILITY,OUTPATIENT,,,,63.00 ,44.10 ,Aetna,"AETNA",28.35,45,percent of total billed charges,999999999,18.9,44.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT ORTHO GLASS 4IN X15FT",0271,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT, REUTER BI-VALVE NASAL",0271,,,RC,,,FACILITY,OUTPATIENT,,,,225.00 ,157.50 ,Aetna,"AETNA",101.25,45,percent of total billed charges,999999999,67.5,157.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STOCKINETTE",0271,,,RC,,,FACILITY,OUTPATIENT,,,,14.00 ,9.80 ,Aetna,"AETNA",6.30,45,percent of total billed charges,999999999,4.2,9.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TEETHGUARD (ENT)",0271,,,RC,,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRACTION HALTER, DISKARD",0271,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, BLOOD WARMING HOTLINE",0271,,,RC,,,FACILITY,OUTPATIENT,,,,78.00 ,54.60 ,Aetna,"AETNA",35.10,45,percent of total billed charges,999999999,23.4,54.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ULNA NERVE PROTECTOR (PAIR)",0271,,,RC,,,FACILITY,OUTPATIENT,,,,18.00 ,12.60 ,Aetna,"AETNA",8.10,45,percent of total billed charges,999999999,5.4,12.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MAMMORY SUPPORT",0271,,,RC,,,FACILITY,OUTPATIENT,,,,228.00 ,159.60 ,Aetna,"AETNA",102.60,45,percent of total billed charges,999999999,68.4,159.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPLINT, OCL",0271,,,RC,,,FACILITY,OUTPATIENT,,,,77.00 ,53.90 ,Aetna,"AETNA",34.65,45,percent of total billed charges,999999999,23.1,53.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"LACTATED RINGERS IR SOLN",0271,,00264220300,RC,,NDC,FACILITY,OUTPATIENT,1000,ML,,46.13 ,32.29 ,Aetna,"AETNA",20.76,45,percent of total billed charges,999999999,13.839,32.291,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CERVICAL RIPENING BALLOON",0272,C1726,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,261.00 ,182.70 ,Aetna,"AETNA",1224.92,308.7,fee schedule,999999999,78.3,1224.9216,fee schedule,""
"HCHG CATH THERML DILUT 7FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,258.00 ,180.60 ,Aetna,"AETNA",116.10,45,percent of total billed charges,999999999,77.4,180.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG INLINE AUTO TRANS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,141.00 ,98.70 ,Aetna,"AETNA",63.45,45,percent of total billed charges,999999999,42.3,98.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE PACK, DISP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,41.00 ,28.70 ,Aetna,"AETNA",18.45,45,percent of total billed charges,999999999,12.3,28.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUGICEL SNOW ABSORBABLE HEROSTAT 2X4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,609.00 ,426.30 ,Aetna,"AETNA",274.05,45,percent of total billed charges,999999999,182.7,426.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUGICEL SNOW ABSORBABLE HEROSTAT 4X4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,743.00 ,520.10 ,Aetna,"AETNA",334.35,45,percent of total billed charges,999999999,222.9,520.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LIGASURE SMALL JAW",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2334.00 ,1633.80 ,Aetna,"AETNA",1050.30,45,percent of total billed charges,999999999,700.2,1633.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LIGASURE IMPACT LARGE JAW",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2808.00 ,1965.60 ,Aetna,"AETNA",1263.60,45,percent of total billed charges,999999999,842.4,1965.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 2 KLING STERILE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 3 KLING STERILE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 9.5 FR. GROSHONG REPAIR KIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,548.00 ,383.60 ,Aetna,"AETNA",246.60,45,percent of total billed charges,999999999,164.4,383.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ABSORBANT-ANTI MICROBIAL 7 DAY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,77.00 ,53.90 ,Aetna,"AETNA",34.65,45,percent of total billed charges,999999999,23.1,53.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ABSORBANT-ANTI MICROBIAL 4X5",0272,,,RC,,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,14.7,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ADAPTIC DRSG 3X8",0272,A6223,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,9.00 ,6.30 ,Aetna,"AETNA",4.05,45,percent of total billed charges,999999999,2.7,6.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FOAM ADHESIVE 4X4",0272,A6212,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FOAM-NON ADHESIVE 5X5",0272,A6213,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",45.93,308.7,fee schedule,999999999,6,45.93456,fee schedule,""
"HCHG FOAM-NON ADHESIVE 4X4",0272,A6212,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROFIBER 4X4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,22.00 ,15.40 ,Aetna,"AETNA",9.90,45,percent of total billed charges,999999999,6.6,15.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROFIBER SILVER 6X6",0272,,,RC,,,FACILITY,OUTPATIENT,,,,46.00 ,32.20 ,Aetna,"AETNA",20.70,45,percent of total billed charges,999999999,13.8,32.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SILVER POWDER 5 GM BOTTLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,108.00 ,75.60 ,Aetna,"AETNA",48.60,45,percent of total billed charges,999999999,32.4,75.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BULKY ROLL STERILE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,7.00 ,4.90 ,Aetna,"AETNA",3.15,45,percent of total billed charges,999999999,2.1,4.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATHETER EXTRA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATHLON EXTRA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE SELF ADHER ELASTIC 3",0272,A6454,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DERMABOND SKIN ADHESIVE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,204.00 ,142.80 ,Aetna,"AETNA",91.80,45,percent of total billed charges,999999999,61.2,142.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 4FR ULTIMATE CATHETER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,137.00 ,95.90 ,Aetna,"AETNA",61.65,45,percent of total billed charges,999999999,41.1,95.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DOPPLER NEEDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,510.00 ,357.00 ,Aetna,"AETNA",229.50,45,percent of total billed charges,999999999,153,357,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DOUBLE LUMEN CATH 4 FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,534.00 ,373.80 ,Aetna,"AETNA",240.30,45,percent of total billed charges,999999999,160.2,373.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRESSING LARGE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,38.00 ,26.60 ,Aetna,"AETNA",17.10,45,percent of total billed charges,999999999,11.4,26.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRESSING MEDIUM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRESSING-CA ALGINATE 6X8",0272,A6197,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRESSING-CA ALGINATE ROPE 12",0272,A6199,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,33.00 ,23.10 ,Aetna,"AETNA",14.85,45,percent of total billed charges,999999999,9.9,23.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXTRA SUTURE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,14.7,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROGEL 3 OZ",0272,A6248,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,55.00 ,38.50 ,Aetna,"AETNA",24.75,45,percent of total billed charges,999999999,16.5,38.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEIMLICH VALVE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,107.00 ,74.90 ,Aetna,"AETNA",48.15,45,percent of total billed charges,999999999,32.1,74.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HUBER NEEDLE",0272,A4212,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,40.00 ,28.00 ,Aetna,"AETNA",18.15,308.7,fee schedule,999999999,12,28,fee schedule,""
"HCHG INTEROSSEOUS 18 G NEEDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,95.00 ,66.50 ,Aetna,"AETNA",42.75,45,percent of total billed charges,999999999,28.5,66.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INTRA-AORTIC BALOON PUMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,900,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KLING/KERLIX/EXTRA",0272,A6403,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,7.00 ,4.90 ,Aetna,"AETNA",3.15,45,percent of total billed charges,999999999,2.1,4.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NG TUBE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FILM TRANSPARENT 3 3X8 X 3 3/4",0272,A6257,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 4FR MPA1 100CM DIAG CATH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,203.00 ,142.10 ,Aetna,"AETNA",91.35,45,percent of total billed charges,999999999,60.9,142.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE DISCECTOMY LUMBAR PERC",0272,C2614,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,4625.00 ,3237.50 ,Aetna,"AETNA",721.00,308.7,fee schedule,999999999,720.99972,3237.5,fee schedule,""
"HCHG BANDAGE-4 LAYER COMPRESSION",0272,,,RC,,,FACILITY,OUTPATIENT,,,,58.00 ,40.60 ,Aetna,"AETNA",26.10,45,percent of total billed charges,999999999,17.4,40.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PTCA ACCESORY KIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,210.00 ,147.00 ,Aetna,"AETNA",94.50,45,percent of total billed charges,999999999,63,147,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROCOLLOID 6X6",0272,A6235,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROCOLLOID 4X4",0272,A6235,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,21.00 ,14.70 ,Aetna,"AETNA",9.45,45,percent of total billed charges,999999999,6.3,14.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RECOVERY CONE REMOVAL SYSTEM",0272,C1773,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,2375.00 ,1662.50 ,Aetna,"AETNA",216.09,308.7,fee schedule,999999999,216.09,1662.5,fee schedule,""
"HCHG ROLL, STERILE, BULKY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,7.00 ,4.90 ,Aetna,"AETNA",3.15,45,percent of total billed charges,999999999,2.1,4.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RT ANGLED CHEST TUBE #36F",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,21,49,fee schedule,""
"HCHG CATHETER,VENOGRAM BALLOON",0272,C2628,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,600.00 ,420.00 ,Aetna,"AETNA",1728.72,308.7,fee schedule,999999999,180,1728.72,fee schedule,""
"HCHG SEPRA FILM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE GAUZE 4X4 10/PK",0272,A6402,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE GAUZE 4X4 2/PK",0272,A6402,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER,SKIN,DISP.",0272,,,RC,,,FACILITY,OUTPATIENT,,,,55.00 ,38.50 ,Aetna,"AETNA",24.75,45,percent of total billed charges,999999999,16.5,38.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STEINMAN PIN",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,36.00 ,25.20 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,10.8,979.38162,fee schedule,""
"HCHG STRIP PACKING PLAIN 1/2",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRIP PACKING PLAIN STER 1",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,16.00 ,11.20 ,Aetna,"AETNA",7.20,45,percent of total billed charges,999999999,4.8,11.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRIP PACKING PLAIN STER 1/4",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRIP PACKING STER 1/4IODOFOM",0272,A6266,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.2,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ROLL-SOFT CONFORMING 4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,6.00 ,4.20 ,Aetna,"AETNA",2.70,45,percent of total billed charges,999999999,1.8,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CARTO3 REF PATCH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1665.00 ,1165.50 ,Aetna,"AETNA",749.25,45,percent of total billed charges,999999999,499.5,1165.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TELFA 8X10",0272,A6402,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,18.00 ,12.60 ,Aetna,"AETNA",8.10,45,percent of total billed charges,999999999,5.4,12.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 7.5FR EDWARDS SWAN/THERMO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,540.00 ,378.00 ,Aetna,"AETNA",243.00,45,percent of total billed charges,999999999,162,378,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DOUBLE TRANSDUCER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,145.00 ,101.50 ,Aetna,"AETNA",65.25,45,percent of total billed charges,999999999,43.5,101.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROGEL WOUND DRESSING 3.75X3.75",0272,A6242,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,23.00 ,16.10 ,Aetna,"AETNA",10.35,45,percent of total billed charges,999999999,6.9,16.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HYDROGEL WOUND DRESSING 6X8",0272,A6243,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,52.00 ,36.40 ,Aetna,"AETNA",23.40,45,percent of total billed charges,999999999,15.6,36.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBI-GRIP SZ D/YD",0272,A6457,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBI-GRIP SZ E/YD",0272,A6457,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,31.00 ,21.70 ,Aetna,"AETNA",13.95,45,percent of total billed charges,999999999,9.3,21.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG URIMETER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG VALVULOPLASTY BALLOON-AORTIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2106.00 ,1474.20 ,Aetna,"AETNA",947.70,45,percent of total billed charges,999999999,631.8,1474.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CRANIAL ACCESS KIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1375.00 ,962.50 ,Aetna,"AETNA",618.75,45,percent of total billed charges,999999999,412.5,962.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FOAM SILICONE 4X4",0272,A6212,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,34.00 ,23.80 ,Aetna,"AETNA",15.30,45,percent of total billed charges,999999999,10.2,23.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RETRACTOR C SECTION XL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,482.00 ,337.40 ,Aetna,"AETNA",216.90,45,percent of total billed charges,999999999,144.6,337.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RETRACTOR C SECTION LG",0272,,,RC,,,FACILITY,OUTPATIENT,,,,369.00 ,258.30 ,Aetna,"AETNA",166.05,45,percent of total billed charges,999999999,110.7,258.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SIZING BALLOON AMPLATZER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1945.00 ,1361.50 ,Aetna,"AETNA",875.25,45,percent of total billed charges,999999999,583.5,1361.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXTENDER LEAD BULLDOG",0272,C1883,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,990.00 ,693.00 ,Aetna,"AETNA",88.16,308.7,fee schedule,999999999,88.16472,693,fee schedule,""
"HCHG STAPLER,SKIN 35W PREM(CATHLAB)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,164.00 ,114.80 ,Aetna,"AETNA",73.80,45,percent of total billed charges,999999999,49.2,114.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DIABETISOURCE AC FORMULA 1 LTR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,34.00 ,23.80 ,Aetna,"AETNA",15.30,45,percent of total billed charges,999999999,10.2,23.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG VENTRICULAR ASSIST DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,75000.00 ,52500.00 ,Aetna,"AETNA",33750.00,45,percent of total billed charges,999999999,6541,52500,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRACH TUBE,UNIPERC ADJFLNG 8.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1499.00 ,1049.30 ,Aetna,"AETNA",674.55,45,percent of total billed charges,999999999,449.7,1049.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CUFFED ET TUBE 3.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,57.00 ,39.90 ,Aetna,"AETNA",25.65,45,percent of total billed charges,999999999,17.1,39.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LAMINARIA ALL SZS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,76.00 ,53.20 ,Aetna,"AETNA",34.20,45,percent of total billed charges,999999999,22.8,53.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DIAGNOSTIC CATH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,58.00 ,40.60 ,Aetna,"AETNA",26.10,45,percent of total billed charges,999999999,17.4,40.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SINGLE TRANSDUCER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAYLIS TRANSSEPTAL NEEDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2475.00 ,1732.50 ,Aetna,"AETNA",1113.75,45,percent of total billed charges,999999999,742.5,1732.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG 6FR ARROW SWAN/THERMO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,660.00 ,462.00 ,Aetna,"AETNA",297.00,45,percent of total billed charges,999999999,198,462,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG OXYGENATOR PERFUSION HLS SET ADVANCED 7.0 ADULT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,53778.76 ,37645.13 ,Aetna,"AETNA",24200.44,45,percent of total billed charges,999999999,6541,37645.132,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA ARTERIAL 2 SIDEHOLE LUER LOCK HLS BIOLINE STERILE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1640.00 ,1148.00 ,Aetna,"AETNA",738.00,45,percent of total billed charges,999999999,492,1148,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT INSERTION GUIDEWIRE PERCUTANEOUS STERILE LATEX FREE DISPOSABLE 150CM .038IN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1339.00 ,937.30 ,Aetna,"AETNA",602.55,45,percent of total billed charges,999999999,401.7,937.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PIK DILATOR SET L",0272,,,RC,,,FACILITY,OUTPATIENT,,,,601.00 ,420.70 ,Aetna,"AETNA",270.45,45,percent of total billed charges,999999999,180.3,420.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA ARTERIAL PERFORATION CONNECTOR CATHETER BIOLINE HLS VENOUS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2241.00 ,1568.70 ,Aetna,"AETNA",1008.45,45,percent of total billed charges,999999999,672.3,1568.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT VASCULAR AVALON ELITE ACCESS STERILE LATEX FREE DISPOSABLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,711.00 ,497.70 ,Aetna,"AETNA",319.95,45,percent of total billed charges,999999999,213.3,497.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATHETER INFUSION DUAL LUMEN BICAVAL RADIOPAQUE AVALONELITE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,10710.18 ,7497.13 ,Aetna,"AETNA",4819.58,45,percent of total billed charges,999999999,3213.054,7497.126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH BERMAN ALL SIZES",0272,,,RC,,,FACILITY,OUTPATIENT,,,,960.00 ,672.00 ,Aetna,"AETNA",432.00,45,percent of total billed charges,999999999,288,672,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH 4FR SRAIGHT TIP PIGTAIL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,72.00 ,50.40 ,Aetna,"AETNA",32.40,45,percent of total billed charges,999999999,21.6,50.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH 3.3FR MONGOOSE PIGTAIL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,750.00 ,525.00 ,Aetna,"AETNA",337.50,45,percent of total billed charges,999999999,225,525,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHEATH 3.3FR PEDIAVASCULAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,90,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STENT PANCREATIC PUSHER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,338.00 ,236.60 ,Aetna,"AETNA",152.10,45,percent of total billed charges,999999999,101.4,236.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FOLEY CATH TRAY",0272,A4311,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,16.39,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ADHESIVE, DERMABOND",0272,,,RC,,,FACILITY,OUTPATIENT,,,,159.00 ,111.30 ,Aetna,"AETNA",71.55,45,percent of total billed charges,999999999,47.7,111.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG APPLICATOR TIP, BIOGLUE 27CM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,266.00 ,186.20 ,Aetna,"AETNA",119.70,45,percent of total billed charges,999999999,79.8,186.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARGON COAG 10MM PROBE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,600.00 ,420.00 ,Aetna,"AETNA",270.00,45,percent of total billed charges,999999999,180,420,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARGON COAG TRPL OPTION HC PENCIL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,332.00 ,232.40 ,Aetna,"AETNA",149.40,45,percent of total billed charges,999999999,99.6,232.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARTHROWAND COVAC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ARTHROWAND TURBOVAC 3.5/90 SUCT.",0272,,,RC,,,FACILITY,OUTPATIENT,,,,967.00 ,676.90 ,Aetna,"AETNA",435.15,45,percent of total billed charges,999999999,290.1,676.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BABCOCK, ENDO 10MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,475.00 ,332.50 ,Aetna,"AETNA",213.75,45,percent of total billed charges,999999999,142.5,332.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BACKGROUND MATERIAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,53.00 ,37.10 ,Aetna,"AETNA",23.85,45,percent of total billed charges,999999999,15.9,37.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, BILE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,63.00 ,44.10 ,Aetna,"AETNA",28.35,45,percent of total billed charges,999999999,18.9,44.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, DRAINAGE URINARY 4000ML",0272,A4357,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,41.00 ,28.70 ,Aetna,"AETNA",18.45,45,percent of total billed charges,999999999,10.73,28.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, DRAINAGE UROVIEW(RM2 TABLE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,65.00 ,45.50 ,Aetna,"AETNA",29.25,45,percent of total billed charges,999999999,19.5,45.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG, FLUID COLLECT. ANGIOFILL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,50.00 ,35.00 ,Aetna,"AETNA",22.50,45,percent of total billed charges,999999999,15,35,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAG-A-JET",0272,,,RC,,,FACILITY,OUTPATIENT,,,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,3,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BALLOON, TROCAR FOR HERNIA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,787.00 ,550.90 ,Aetna,"AETNA",354.15,45,percent of total billed charges,999999999,236.1,550.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BANDAGE, COBAN ELASTIC",0272,A6454,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BASKET",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1068.00 ,747.60 ,Aetna,"AETNA",480.60,45,percent of total billed charges,999999999,320.4,747.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BASKET, SEGURA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1091.00 ,763.70 ,Aetna,"AETNA",490.95,45,percent of total billed charges,999999999,327.3,763.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, BEAVER (EYE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,17.00 ,11.90 ,Aetna,"AETNA",7.65,45,percent of total billed charges,999999999,5.1,11.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, BEAVER (OHS)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,45.00 ,31.50 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,13.5,31.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, CURVED 4.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,544.00 ,380.80 ,Aetna,"AETNA",244.80,45,percent of total billed charges,999999999,163.2,380.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, DERMATOME NEW AIR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,205.00 ,143.50 ,Aetna,"AETNA",92.25,45,percent of total billed charges,999999999,61.5,143.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, INDIANATOME",0272,,,RC,,,FACILITY,OUTPATIENT,,,,899.00 ,629.30 ,Aetna,"AETNA",404.55,45,percent of total billed charges,999999999,269.7,629.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, OSCILLATING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, RADENOID CURVD PED.",0272,,,RC,,,FACILITY,OUTPATIENT,,,,473.00 ,331.10 ,Aetna,"AETNA",212.85,45,percent of total billed charges,999999999,141.9,331.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BLADE, SAGITTAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,39.00 ,27.30 ,Aetna,"AETNA",17.55,45,percent of total billed charges,999999999,11.7,27.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE BIOPSY DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,780.00 ,546.00 ,Aetna,"AETNA",351.00,45,percent of total billed charges,999999999,234,546,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE CEMENT MIXER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,789.00 ,552.30 ,Aetna,"AETNA",355.05,45,percent of total billed charges,999999999,236.7,552.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE CEMENT MIXER (MIX-E-VAC II)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,311.00 ,217.70 ,Aetna,"AETNA",139.95,45,percent of total billed charges,999999999,93.3,217.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE MILL BM200",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1123.00 ,786.10 ,Aetna,"AETNA",505.35,45,percent of total billed charges,999999999,336.9,786.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE WAX",0272,,,RC,,,FACILITY,OUTPATIENT,,,,34.00 ,23.80 ,Aetna,"AETNA",15.30,45,percent of total billed charges,999999999,10.2,23.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, BLADE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,45.00 ,31.50 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,13.5,31.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, CONTROL W/BLADE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, HANDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,51.00 ,35.70 ,Aetna,"AETNA",22.95,45,percent of total billed charges,999999999,15.3,35.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, NEEDLE TIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,99.00 ,69.30 ,Aetna,"AETNA",44.55,45,percent of total billed charges,999999999,29.7,69.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, NEEDLE TIP 1",0272,,,RC,,,FACILITY,OUTPATIENT,,,,9.00 ,6.30 ,Aetna,"AETNA",4.05,45,percent of total billed charges,999999999,2.7,6.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, NEEDLE TIP 3CM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,262.00 ,183.40 ,Aetna,"AETNA",117.90,45,percent of total billed charges,999999999,78.6,183.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BOVIE, NEEDLE TIP 6 EXTEN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BURR, EGG 4.0 (ORAL)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BURR, ROUND",0272,,,RC,,,FACILITY,OUTPATIENT,,,,77.00 ,53.90 ,Aetna,"AETNA",34.65,45,percent of total billed charges,999999999,23.1,53.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA KIT, UNIV GREY-SHOULDER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,156.00 ,109.20 ,Aetna,"AETNA",70.20,45,percent of total billed charges,999999999,46.8,109.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA, ANTERIOR CHAMBER RND*",0272,,,RC,,,FACILITY,OUTPATIENT,,,,32.00 ,22.40 ,Aetna,"AETNA",14.40,45,percent of total billed charges,999999999,9.6,22.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INCISIVE SKIN CLOSURE STAPLE 2030",0272,,,RC,,,FACILITY,OUTPATIENT,,,,173.00 ,121.10 ,Aetna,"AETNA",77.85,45,percent of total billed charges,999999999,51.9,121.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA, THRDED 8.4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,140.00 ,98.00 ,Aetna,"AETNA",63.00,45,percent of total billed charges,999999999,42,98,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA, TIB TUNNEL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,114.00 ,79.80 ,Aetna,"AETNA",51.30,45,percent of total billed charges,999999999,34.2,79.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH CONNECTOR, URET",0272,C1758,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,93.00 ,65.10 ,Aetna,"AETNA",213.00,308.7,fee schedule,999999999,27.9,213.003,fee schedule,""
"HCHG CATH KIT, Y TEC SYSTEM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH SET, MALECOT NEPH RNTRY 24F",0272,,,RC,,,FACILITY,OUTPATIENT,,,,570.00 ,399.00 ,Aetna,"AETNA",256.50,45,percent of total billed charges,999999999,171,399,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, ANGIO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,89.00 ,62.30 ,Aetna,"AETNA",40.05,45,percent of total billed charges,999999999,26.7,62.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, CHOLANGIOGRAM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,160.00 ,112.00 ,Aetna,"AETNA",72.00,45,percent of total billed charges,999999999,48,112,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 12FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,83.00 ,58.10 ,Aetna,"AETNA",37.35,45,percent of total billed charges,999999999,28.22,58.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 14FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,83.00 ,58.10 ,Aetna,"AETNA",37.35,45,percent of total billed charges,999999999,28.22,58.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 16 FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,28.56,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 18 FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,86.00 ,60.20 ,Aetna,"AETNA",38.70,45,percent of total billed charges,999999999,29.24,60.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 20FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,23.8,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 22FR 5CC",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,88.00 ,61.60 ,Aetna,"AETNA",39.60,45,percent of total billed charges,999999999,29.84,61.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUNCIL TIP 16FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,102.00 ,71.40 ,Aetna,"AETNA",45.90,45,percent of total billed charges,999999999,30.6,71.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUNCIL TIP 18FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,97.00 ,67.90 ,Aetna,"AETNA",43.65,45,percent of total billed charges,999999999,29.1,67.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUNCIL TIP 20FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,123.00 ,86.10 ,Aetna,"AETNA",55.35,45,percent of total billed charges,999999999,36.9,86.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUNCIL TIP 22FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,98.00 ,68.60 ,Aetna,"AETNA",44.10,45,percent of total billed charges,999999999,29.4,68.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUNCIL TIP 24FR (NEPH)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,254.00 ,177.80 ,Aetna,"AETNA",114.30,45,percent of total billed charges,999999999,76.2,177.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOGARTY OCC BALLOON",0272,C2628,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,471.00 ,329.70 ,Aetna,"AETNA",1728.72,308.7,fee schedule,999999999,141.3,1728.72,fee schedule,""
"HCHG CATH, FOLEY 12FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,62.00 ,43.40 ,Aetna,"AETNA",27.90,45,percent of total billed charges,999999999,13.56,43.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 14FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,62.00 ,43.40 ,Aetna,"AETNA",27.90,45,percent of total billed charges,999999999,13.56,43.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 16FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,63.00 ,44.10 ,Aetna,"AETNA",28.35,45,percent of total billed charges,999999999,13.56,44.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 18 FR 30CC 3-WAY",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,67.00 ,46.90 ,Aetna,"AETNA",30.15,45,percent of total billed charges,999999999,13.56,46.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 20FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,66.00 ,46.20 ,Aetna,"AETNA",29.70,45,percent of total billed charges,999999999,13.56,46.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 22FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,46.00 ,32.20 ,Aetna,"AETNA",20.70,45,percent of total billed charges,999999999,13.56,32.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 22FR 30CC 3-WAY",0272,A4346,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,21.28,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 24FR",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,62.00 ,43.40 ,Aetna,"AETNA",27.90,45,percent of total billed charges,999999999,13.56,43.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY 26FR 30CC 2-WAY",0272,A4338,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,23.00 ,16.10 ,Aetna,"AETNA",10.35,45,percent of total billed charges,999999999,7.82,16.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY SILICONE 14,16FR",0272,A4344,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,17.7,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY SILICONE 18FR 5CC",0272,A4346,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,79.00 ,55.30 ,Aetna,"AETNA",35.55,45,percent of total billed charges,999999999,21.28,55.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY SILICONE 20FR",0272,A4346,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,76.00 ,53.20 ,Aetna,"AETNA",34.20,45,percent of total billed charges,999999999,21.28,53.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, FOLEY SILICONE 24FR",0272,A4346,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,86.00 ,60.20 ,Aetna,"AETNA",38.70,45,percent of total billed charges,999999999,21.28,60.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, GLIDE STR TAPER 5FR 100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,398.00 ,278.60 ,Aetna,"AETNA",179.10,45,percent of total billed charges,999999999,119.4,278.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, HEYMAN FOLLOWER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,71.00 ,49.70 ,Aetna,"AETNA",31.95,45,percent of total billed charges,999999999,21.3,49.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, ICP SUBDURAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, IRRIG OCC PRUITT",0272,C2628,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,748.00 ,523.60 ,Aetna,"AETNA",1728.72,308.7,fee schedule,999999999,224.4,1728.72,fee schedule,""
"HCHG CATH, LAPAROSCOPIC CHOLANGIO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,588.00 ,411.60 ,Aetna,"AETNA",264.60,45,percent of total billed charges,999999999,176.4,411.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, LUMBAR HERMETIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,731.00 ,511.70 ,Aetna,"AETNA",328.95,45,percent of total billed charges,999999999,219.3,511.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, MALECOT",0272,A4340,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,143.00 ,100.10 ,Aetna,"AETNA",64.35,45,percent of total billed charges,999999999,29.84,100.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, REDDICK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,515.00 ,360.50 ,Aetna,"AETNA",231.75,45,percent of total billed charges,999999999,154.5,360.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, ROBINSON",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, SIZING OMNI 5F 70CM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, SUCTION 08FR X 14 REG VAC",0272,A4624,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,14.00 ,9.80 ,Aetna,"AETNA",9.97,308.7,fee schedule,999999999,4.2,9.97101,fee schedule,""
"CATH, SUCTION 14FR W/CONT PORT",0272,A4624,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",9.97,308.7,fee schedule,999999999,1.5,9.97101,fee schedule,""
"HCHG CATH, THERMAL DILUTION 7FR SWAN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,258.00 ,180.60 ,Aetna,"AETNA",116.10,45,percent of total billed charges,999999999,77.4,180.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, THORACIC 28FR W/SENTNL EYE",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,42.00 ,29.40 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,12.6,34.2657,fee schedule,""
"HCHG CAUTERY, DISP (EYE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,162.00 ,113.40 ,Aetna,"AETNA",72.90,45,percent of total billed charges,999999999,48.6,113.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CAUTERY, OPTHTHALMIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,48.00 ,33.60 ,Aetna,"AETNA",21.60,45,percent of total billed charges,999999999,14.4,33.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CEMENT, SCULPS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,187.00 ,130.90 ,Aetna,"AETNA",84.15,45,percent of total billed charges,999999999,56.1,130.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLAMP, BULLDOG 1/2 FORCE BLUE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,108.00 ,75.60 ,Aetna,"AETNA",48.60,45,percent of total billed charges,999999999,32.4,75.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLIP, ANASTOMOTIC DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,945.00 ,661.50 ,Aetna,"AETNA",425.25,45,percent of total billed charges,999999999,283.5,661.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLIP, HEMOLOCK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,101.00 ,70.70 ,Aetna,"AETNA",45.45,45,percent of total billed charges,999999999,30.3,70.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLIP, LIGACLIP EXTRA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,39.00 ,27.30 ,Aetna,"AETNA",17.55,45,percent of total billed charges,999999999,11.7,27.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLIP, SCALP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,14.7,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CONFORMER, EYE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,85.00 ,59.50 ,Aetna,"AETNA",38.25,45,percent of total billed charges,999999999,25.5,59.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CONNECTOR, BLAKE DRAIN 1-WAY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,34.00 ,23.80 ,Aetna,"AETNA",15.30,45,percent of total billed charges,999999999,10.2,23.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CORNEAL LIGHT SHIELD",0272,,,RC,,,FACILITY,OUTPATIENT,,,,47.00 ,32.90 ,Aetna,"AETNA",21.15,45,percent of total billed charges,999999999,14.1,32.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG COTTONOID, SURG PATTIE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CURRETTE TIP, VAC CURV",0272,,,RC,,,FACILITY,OUTPATIENT,,,,29.00 ,20.30 ,Aetna,"AETNA",13.05,45,percent of total billed charges,999999999,8.7,20.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CURRETTE TIP, VAC ST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,29.00 ,20.30 ,Aetna,"AETNA",13.05,45,percent of total billed charges,999999999,8.7,20.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CUTTING LOOP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,441.00 ,308.70 ,Aetna,"AETNA",198.45,45,percent of total billed charges,999999999,132.3,308.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DERMACARRIER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,147.00 ,102.90 ,Aetna,"AETNA",66.15,45,percent of total billed charges,999999999,44.1,102.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DILATOR, (COOK) .035 WIRE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,10.5,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DILATORS, PARSONNET (OHS)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,396.00 ,277.20 ,Aetna,"AETNA",178.20,45,percent of total billed charges,999999999,118.8,277.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DISSECT TOOL, ANSPACH S",0272,,,RC,,,FACILITY,OUTPATIENT,,,,390.00 ,273.00 ,Aetna,"AETNA",175.50,45,percent of total billed charges,999999999,117,273,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DISSECT TOOL, MIDAS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,486.00 ,340.20 ,Aetna,"AETNA",218.70,45,percent of total billed charges,999999999,145.8,340.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN KIT, HEMOVAC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,262.00 ,183.40 ,Aetna,"AETNA",117.90,45,percent of total billed charges,999999999,78.6,183.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, 7MM FLAT-FLUTED",0272,,,RC,,,FACILITY,OUTPATIENT,,,,134.00 ,93.80 ,Aetna,"AETNA",60.30,45,percent of total billed charges,999999999,40.2,93.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, ABRAMSON SUMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,251.00 ,175.70 ,Aetna,"AETNA",112.95,45,percent of total billed charges,999999999,75.3,175.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, AUTO TRANS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,599.00 ,419.30 ,Aetna,"AETNA",269.55,45,percent of total billed charges,999999999,179.7,419.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, BLAKE 10MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,136.00 ,95.20 ,Aetna,"AETNA",61.20,45,percent of total billed charges,999999999,40.8,95.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-P FLAT 10MM 7044",0272,,,RC,,,FACILITY,OUTPATIENT,,,,46.00 ,32.20 ,Aetna,"AETNA",20.70,45,percent of total billed charges,999999999,13.8,32.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-P FLAT 7MM FULL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,47.00 ,32.90 ,Aetna,"AETNA",21.15,45,percent of total billed charges,999999999,14.1,32.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-P ROUND 10FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,63.00 ,44.10 ,Aetna,"AETNA",28.35,45,percent of total billed charges,999999999,18.9,44.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-P ROUND 15FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,61.00 ,42.70 ,Aetna,"AETNA",27.45,45,percent of total billed charges,999999999,18.3,42.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-P ROUND 19FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,68.00 ,47.60 ,Aetna,"AETNA",30.60,45,percent of total billed charges,999999999,20.4,47.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, J-VAC ROUND 19FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,126.00 ,88.20 ,Aetna,"AETNA",56.70,45,percent of total billed charges,999999999,37.8,88.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PENROSE 1/4X12",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PENROSE 1X12",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PENROSE 1X18",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PENROSE 3/8X12",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PLEUROVAC ADUL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,160.00 ,112.00 ,Aetna,"AETNA",72.00,45,percent of total billed charges,999999999,48,112,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, PLEUROVAC PLUS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,189.00 ,132.30 ,Aetna,"AETNA",85.05,45,percent of total billed charges,999999999,56.7,132.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, RESERVOIR J-VAC 150ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, RESERVOIR SUCT JP 100CC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,40.00 ,28.00 ,Aetna,"AETNA",18.00,45,percent of total billed charges,999999999,12,28,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, T-TUBE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,86.00 ,60.20 ,Aetna,"AETNA",38.70,45,percent of total billed charges,999999999,25.8,60.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRAIN, VENTRIC HEYER-SCHULTE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,693.00 ,485.10 ,Aetna,"AETNA",311.85,45,percent of total billed charges,999999999,207.9,485.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT, SURGICEL 2X3",0272,,,RC,,,FACILITY,OUTPATIENT,,,,82.00 ,57.40 ,Aetna,"AETNA",36.90,45,percent of total billed charges,999999999,24.6,57.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT, SURGICEL 4X8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,228.00 ,159.60 ,Aetna,"AETNA",102.60,45,percent of total billed charges,999999999,68.4,159.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT, SURGICAL 6X9",0272,,,RC,,,FACILITY,OUTPATIENT,,,,804.00 ,562.80 ,Aetna,"AETNA",361.80,45,percent of total billed charges,999999999,241.2,562.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, 1.8 SYN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,644.00 ,450.80 ,Aetna,"AETNA",289.80,45,percent of total billed charges,999999999,193.2,450.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, 2.5 SYN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,250.00 ,175.00 ,Aetna,"AETNA",112.50,45,percent of total billed charges,999999999,75,175,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, CANNULATED",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1712.00 ,1198.40 ,Aetna,"AETNA",770.40,45,percent of total billed charges,999999999,513.6,1198.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, CANNULATED 3.5",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1122.00 ,785.40 ,Aetna,"AETNA",504.90,45,percent of total billed charges,999999999,336.6,785.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, ASIF",0272,,,RC,,,FACILITY,OUTPATIENT,,,,317.00 ,221.90 ,Aetna,"AETNA",142.65,45,percent of total billed charges,999999999,95.1,221.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, ASIF 2MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,289.00 ,202.30 ,Aetna,"AETNA",130.05,45,percent of total billed charges,999999999,86.7,202.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, R-T TRIGEN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,474.00 ,331.80 ,Aetna,"AETNA",213.30,45,percent of total billed charges,999999999,142.2,331.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, STRYKER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,444.00 ,310.80 ,Aetna,"AETNA",199.80,45,percent of total billed charges,999999999,133.2,310.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, STRYKER IMF",0272,,,RC,,,FACILITY,OUTPATIENT,,,,424.00 ,296.80 ,Aetna,"AETNA",190.80,45,percent of total billed charges,999999999,127.2,296.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, SYN CANN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1211.00 ,847.70 ,Aetna,"AETNA",544.95,45,percent of total billed charges,999999999,363.3,847.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DURASHPERE INJ. NEEDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, COAG. TONGUE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1677.00 ,1173.90 ,Aetna,"AETNA",754.65,45,percent of total billed charges,999999999,503.1,1173.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, COAG. TURBINATE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,840.00 ,588.00 ,Aetna,"AETNA",378.00,45,percent of total billed charges,999999999,252,588,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, KNIFE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,531.00 ,371.70 ,Aetna,"AETNA",238.95,45,percent of total billed charges,999999999,159.3,371.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, LEEP 3MM (BALL)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,25.2,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, ROLLER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,455.00 ,318.50 ,Aetna,"AETNA",204.75,45,percent of total billed charges,999999999,136.5,318.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ELECTRODE, ROLLER BALL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDO PEANUT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,171.00 ,119.70 ,Aetna,"AETNA",76.95,45,percent of total billed charges,999999999,51.3,119.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDO RETRACTOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,738.00 ,516.60 ,Aetna,"AETNA",332.10,45,percent of total billed charges,999999999,221.4,516.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDOCLIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,644.00 ,450.80 ,Aetna,"AETNA",289.80,45,percent of total billed charges,999999999,193.2,450.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDOCLOSE SUTURING DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,164.00 ,114.80 ,Aetna,"AETNA",73.80,45,percent of total billed charges,999999999,49.2,114.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDOLOOP II 0 VIOLET 18",0272,,,RC,,,FACILITY,OUTPATIENT,,,,197.00 ,137.90 ,Aetna,"AETNA",88.65,45,percent of total billed charges,999999999,59.1,137.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDOSTITCH LOAD UNIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,130.00 ,91.00 ,Aetna,"AETNA",58.50,45,percent of total billed charges,999999999,39,91,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG ENDOSTITCH SUTURING DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,830.00 ,581.00 ,Aetna,"AETNA",373.50,45,percent of total billed charges,999999999,249,581,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF LG CLAMP OPEN COMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2262.00 ,1583.40 ,Aetna,"AETNA",1017.90,45,percent of total billed charges,999999999,678.6,1583.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF LG CLMP 4-POS MR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",1293.75,45,percent of total billed charges,999999999,862.5,2012.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF LG CLMP 6-POS MR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",1293.75,45,percent of total billed charges,999999999,862.5,2012.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF LG OPEN CLMP MR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2545.00 ,1781.50 ,Aetna,"AETNA",1145.25,45,percent of total billed charges,999999999,763.5,1781.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF LG SCHANZ 5.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,828.00 ,579.60 ,Aetna,"AETNA",372.60,45,percent of total billed charges,999999999,248.4,579.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, ASIF TRANSFIX.PIN",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,674.00 ,471.80 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,202.2,979.38162,fee schedule,""
"HCHG EXFX, SN 5 HALF PIN",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,804.00 ,562.80 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,241.2,979.38162,fee schedule,""
"HCHG EXFX, SN 5X50MM TRACTION PIN",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1173.00 ,821.10 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,351.9,979.38162,fee schedule,""
"HCHG EXFX, SN BAR-BAR CLAMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2875.00 ,2012.50 ,Aetna,"AETNA",1293.75,45,percent of total billed charges,999999999,862.5,2012.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, SN BAR-PIN CLAMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3001.00 ,2100.70 ,Aetna,"AETNA",1350.45,45,percent of total billed charges,999999999,900.3,2100.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXFX, SN MULTIPLE PIN CLAMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2263.00 ,1584.10 ,Aetna,"AETNA",1018.35,45,percent of total billed charges,999999999,678.9,1584.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EYE PAD",0272,A6410,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FIBERSTICK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,189.00 ,132.30 ,Aetna,"AETNA",85.05,45,percent of total billed charges,999999999,56.7,132.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FIBERWIRE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,85.00 ,59.50 ,Aetna,"AETNA",38.25,45,percent of total billed charges,999999999,25.5,59.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FILTER, BLOOD TRANSFUSION, PALL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,62.00 ,43.40 ,Aetna,"AETNA",27.90,45,percent of total billed charges,999999999,18.6,43.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FLOSEAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,945.00 ,661.50 ,Aetna,"AETNA",425.25,45,percent of total billed charges,999999999,283.5,661.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FORCEP, BIPO CUT (EVEREST)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1855.00 ,1298.50 ,Aetna,"AETNA",834.75,45,percent of total billed charges,999999999,556.5,1298.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FORCEP, CUP BIOPSY (SHARK)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,120.00 ,84.00 ,Aetna,"AETNA",54.00,45,percent of total billed charges,999999999,36,84,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FORCEP, GRASPING TRICEP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,956.00 ,669.20 ,Aetna,"AETNA",430.20,45,percent of total billed charges,999999999,286.8,669.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, ADAPTIC 3X3",0272,A6222,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, ADAPTIC 3X8",0272,A6223,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,9.00 ,6.30 ,Aetna,"AETNA",4.05,45,percent of total billed charges,999999999,2.7,6.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, FLUFFS STERILE 36X36",0272,A6403,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,3.3,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, IODOFORM 1",0272,A6266,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,31.00 ,21.70 ,Aetna,"AETNA",13.95,45,percent of total billed charges,999999999,9.3,21.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, IODOFORM 1/2",0272,A6266,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,25.00 ,17.50 ,Aetna,"AETNA",11.25,45,percent of total billed charges,999999999,7.5,17.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, IODOFORM 1/4",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,23.00 ,16.10 ,Aetna,"AETNA",10.35,45,percent of total billed charges,999999999,6.9,16.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, OWENS 3X8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.2,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, VASELINE 1/2X72",0272,A6223,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,9.00 ,6.30 ,Aetna,"AETNA",4.05,45,percent of total billed charges,999999999,2.7,6.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, VASELINE 3X18",0272,A6224,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GAUZE, VASELINE 3X9",0272,A6223,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,6.00 ,4.20 ,Aetna,"AETNA",2.70,45,percent of total billed charges,999999999,1.8,4.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GELPORT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GLUE, BIOGLUE 2CC PRE-FILL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1268.00 ,887.60 ,Aetna,"AETNA",570.60,45,percent of total billed charges,999999999,380.4,887.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GLUE, BIOGLUE 5CC PRE-FILL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GRAFT, MESH SEPRAFILM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,922.00 ,645.40 ,Aetna,"AETNA",414.90,45,percent of total billed charges,999999999,276.6,645.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GRAFT, MESH SEPRAFILM PROPACK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GRASPER, ENDO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,624.00 ,436.80 ,Aetna,"AETNA",280.80,45,percent of total billed charges,999999999,187.2,436.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE PIN, ARTHREX FEM",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,413.00 ,289.10 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,123.9,289.1,fee schedule,""
"HCHG GUIDE PIN, ARTHRX NITINOL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,301.00 ,210.70 ,Aetna,"AETNA",135.45,45,percent of total billed charges,999999999,90.3,210.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE PIN, ASIF DHS/DCS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,209.00 ,146.30 ,Aetna,"AETNA",94.05,45,percent of total billed charges,999999999,62.7,146.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE, R-T FOR 7.0 CANN SCRW",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,151.00 ,105.70 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,45.3,170.18631,fee schedule,""
"HCHG GUIDE PIN, R-T IMHS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,294.00 ,205.80 ,Aetna,"AETNA",132.30,45,percent of total billed charges,999999999,88.2,205.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE WIRE, AO CANN 2.0 THRD",0272,,,RC,,,FACILITY,OUTPATIENT,,,,117.00 ,81.90 ,Aetna,"AETNA",52.65,45,percent of total billed charges,999999999,35.1,81.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE WIRE, AO CANNULATED 1.25",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,21,170.18631,fee schedule,""
"HCHG GUIDE WIRE, AO CANNULATED 1.6",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,177.00 ,123.90 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,53.1,170.18631,fee schedule,""
"HCHG GUIDE WIRE, R-T TRIGEN 3.2",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,493.00 ,345.10 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,147.9,345.1,fee schedule,""
"HCHG HEATER, INSUFLOW DEVICE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,600.00 ,420.00 ,Aetna,"AETNA",270.00,45,percent of total billed charges,999999999,180,420,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOCLIP, LARGE (ORANGE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,10.5,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOCLIP, MEDIUM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,69.00 ,48.30 ,Aetna,"AETNA",31.05,45,percent of total billed charges,999999999,20.7,48.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOCLIP, SMALL (RED)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,67.00 ,46.90 ,Aetna,"AETNA",30.15,45,percent of total billed charges,999999999,20.1,46.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BAKRI TAPENADE BALLOON",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1195.00 ,836.50 ,Aetna,"AETNA",537.75,45,percent of total billed charges,999999999,358.5,836.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INSERT, SOFT-JAW 33MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,22.5,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INSERT, STEALTH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,106.00 ,74.20 ,Aetna,"AETNA",47.70,45,percent of total billed charges,999999999,31.8,74.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, CARPAL TUNNEL ENDOSCOPIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1142.00 ,799.40 ,Aetna,"AETNA",513.90,45,percent of total billed charges,999999999,342.6,799.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, D & E COLLECTION",0272,,,RC,,,FACILITY,OUTPATIENT,,,,82.00 ,57.40 ,Aetna,"AETNA",36.90,45,percent of total billed charges,999999999,24.6,57.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, ENDOSCOPIC VEIN HARVEST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3780.00 ,2646.00 ,Aetna,"AETNA",1701.00,45,percent of total billed charges,999999999,1134,2646,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, FIRST FX",0272,,,RC,,,FACILITY,OUTPATIENT,,,,8758.00 ,6130.60 ,Aetna,"AETNA",3941.10,45,percent of total billed charges,999999999,2627.4,6130.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, GUHL ANKLE DISTRACTOR STRAP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,237.00 ,165.90 ,Aetna,"AETNA",106.65,45,percent of total billed charges,999999999,71.1,165.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, MAMMARY FILL FLUID TRANSFER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,27.00 ,18.90 ,Aetna,"AETNA",12.15,45,percent of total billed charges,999999999,8.1,18.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, PER-FIT 8.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1750.00 ,1225.00 ,Aetna,"AETNA",787.50,45,percent of total billed charges,999999999,525,1225,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, URINE METER",0272,A4314,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,134.00 ,93.80 ,Aetna,"AETNA",60.30,45,percent of total billed charges,999999999,23.76,93.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KNIFE, ACL GRAFT 10MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,364.00 ,254.80 ,Aetna,"AETNA",163.80,45,percent of total billed charges,999999999,109.2,254.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KNIFE, SLIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,90.00 ,63.00 ,Aetna,"AETNA",40.50,45,percent of total billed charges,999999999,27,63,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KNIFE, SLIT 2.75 DUAL BEVEL ANGL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,102.00 ,71.40 ,Aetna,"AETNA",45.90,45,percent of total billed charges,999999999,30.6,71.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KNIFE, STR. COLD URETHROTOME",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1000.00 ,700.00 ,Aetna,"AETNA",450.00,45,percent of total billed charges,999999999,300,700,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LAPAROSCOPIC J/L HOOK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,218.00 ,152.60 ,Aetna,"AETNA",98.10,45,percent of total billed charges,999999999,65.4,152.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LAPRASONIC HOOK PROBE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,969.00 ,678.30 ,Aetna,"AETNA",436.05,45,percent of total billed charges,999999999,290.7,678.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LAPRASONIC ULTRA SHEAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1568.00 ,1097.60 ,Aetna,"AETNA",705.60,45,percent of total billed charges,999999999,470.4,1097.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LASER FIBER, HOLMIUM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2250.00 ,1575.00 ,Aetna,"AETNA",1012.50,45,percent of total billed charges,999999999,675,1575,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LENS/HOOD FOR SPACESUIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,147.00 ,102.90 ,Aetna,"AETNA",66.15,45,percent of total billed charges,999999999,44.1,102.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG LOCATORS, AC VEIN GRAFT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,58.00 ,40.60 ,Aetna,"AETNA",26.10,45,percent of total billed charges,999999999,17.4,40.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MAMMARY SIZER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,270.00 ,189.00 ,Aetna,"AETNA",121.50,45,percent of total billed charges,999999999,81,189,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MASK, LARYNGEAL AIRWAY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MISTER BLOWER, CTS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,90,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, ARTERY RADIAL CATH SET",0272,,,RC,,,FACILITY,OUTPATIENT,,,,55.00 ,38.50 ,Aetna,"AETNA",24.75,45,percent of total billed charges,999999999,16.5,38.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, BIOPSY DISP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,17.00 ,11.90 ,Aetna,"AETNA",7.65,45,percent of total billed charges,999999999,5.1,11.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, BIPOSY ACHIEVE 18X15",0272,,,RC,,,FACILITY,OUTPATIENT,,,,250.00 ,175.00 ,Aetna,"AETNA",112.50,45,percent of total billed charges,999999999,75,175,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, INSUFFLATION FOR STEP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,140.00 ,98.00 ,Aetna,"AETNA",63.00,45,percent of total billed charges,999999999,42,98,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, IRRIG CYSTOTOME 27G",0272,,,RC,,,FACILITY,OUTPATIENT,,,,22.00 ,15.40 ,Aetna,"AETNA",9.90,45,percent of total billed charges,999999999,6.6,15.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, KYPHOPLASTY 11GA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,126.00 ,88.20 ,Aetna,"AETNA",56.70,45,percent of total billed charges,999999999,37.8,88.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, RETROBULBAR (ALL)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,32.00 ,22.40 ,Aetna,"AETNA",14.40,45,percent of total billed charges,999999999,9.6,22.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SCORPION",0272,,,RC,,,FACILITY,OUTPATIENT,,,,840.00 ,588.00 ,Aetna,"AETNA",378.00,45,percent of total billed charges,999999999,252,588,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SPINAL 18G",0272,,,RC,,,FACILITY,OUTPATIENT,,,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,3,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SPINAL 20G/22G",0272,,,RC,,,FACILITY,OUTPATIENT,,,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,3.3,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SPINAL 25G",0272,,,RC,,,FACILITY,OUTPATIENT,,,,11.00 ,7.70 ,Aetna,"AETNA",4.95,45,percent of total billed charges,999999999,3.3,7.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SURGI(VARES)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,86.00 ,60.20 ,Aetna,"AETNA",38.70,45,percent of total billed charges,999999999,25.8,60.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, THINWALL 19GA (COOK)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,19.00 ,13.30 ,Aetna,"AETNA",8.55,45,percent of total billed charges,999999999,5.7,13.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, WILLIAMS CYSTOSCOPIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,100.00 ,70.00 ,Aetna,"AETNA",45.00,45,percent of total billed charges,999999999,30,70,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NERVE STIMULATOR, VARI-STEM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,256.00 ,179.20 ,Aetna,"AETNA",115.20,45,percent of total billed charges,999999999,76.8,179.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG OSTOMY, POUCH 2 1/4 57MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,10.00 ,7.00 ,Aetna,"AETNA",4.50,45,percent of total billed charges,999999999,3,7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, ARTHROSCOPY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,208.00 ,145.60 ,Aetna,"AETNA",93.60,45,percent of total billed charges,999999999,62.4,145.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, CYSTO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,14.7,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, CYSTO W/SEP LEGGINGS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,44.00 ,30.80 ,Aetna,"AETNA",19.80,45,percent of total billed charges,999999999,13.2,30.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, EXTREMITY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,273.00 ,191.10 ,Aetna,"AETNA",122.85,45,percent of total billed charges,999999999,81.9,191.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, EYE CUSTOM CATARACT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,395.00 ,276.50 ,Aetna,"AETNA",177.75,45,percent of total billed charges,999999999,118.5,276.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, HEAD AND NECK (EENT)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,78.00 ,54.60 ,Aetna,"AETNA",35.10,45,percent of total billed charges,999999999,23.4,54.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, LAPAROSCOPY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,252.00 ,176.40 ,Aetna,"AETNA",113.40,45,percent of total billed charges,999999999,75.6,176.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, MAJOR BASIN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,227.00 ,158.90 ,Aetna,"AETNA",102.15,45,percent of total billed charges,999999999,68.1,158.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, MINOR BASIN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,150.00 ,105.00 ,Aetna,"AETNA",67.50,45,percent of total billed charges,999999999,45,105,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, NEURO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,482.00 ,337.40 ,Aetna,"AETNA",216.90,45,percent of total billed charges,999999999,144.6,337.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, OPEN HEART",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, ORTHO MAJOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,396.00 ,277.20 ,Aetna,"AETNA",178.20,45,percent of total billed charges,999999999,118.8,277.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, PERI-GYN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,178.00 ,124.60 ,Aetna,"AETNA",80.10,45,percent of total billed charges,999999999,53.4,124.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, POST VITRECTOMY STORZ",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1214.00 ,849.80 ,Aetna,"AETNA",546.30,45,percent of total billed charges,999999999,364.2,849.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, VASCULAR (FOR ROOM 10)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,424.00 ,296.80 ,Aetna,"AETNA",190.80,45,percent of total billed charges,999999999,127.2,296.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACKING, STRP PLN 1",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,25.00 ,17.50 ,Aetna,"AETNA",11.25,45,percent of total billed charges,999999999,7.5,17.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACKING, STRP PLN 1/2",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACKING, STRP PLN 1/4",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.2,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACKING, STRP PLN 2",0272,A6407,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,32.00 ,22.40 ,Aetna,"AETNA",14.40,45,percent of total billed charges,999999999,9.6,22.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACKING, VAG 2 X-RAY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,31.00 ,21.70 ,Aetna,"AETNA",13.95,45,percent of total billed charges,999999999,9.3,21.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PERFLUORON",0272,C1784,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1922.00 ,1345.40 ,Aetna,"AETNA",88.97,308.7,fee schedule,999999999,88.96734,1345.4,fee schedule,""
"HCHG PERFORATOR, DISP TIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,980.00 ,686.00 ,Aetna,"AETNA",441.00,45,percent of total billed charges,999999999,294,686,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PIN GUARD",0272,,,RC,,,FACILITY,OUTPATIENT,,,,19.00 ,13.30 ,Aetna,"AETNA",8.55,45,percent of total billed charges,999999999,5.7,13.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PIN, HEAD MAYFIELD DISP.",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,135.00 ,94.50 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,40.5,979.38162,fee schedule,""
"HCHG PIN, STEIN 1/8,5/32",0272,,,RC,,,FACILITY,OUTPATIENT,,,,27.00 ,18.90 ,Aetna,"AETNA",12.15,45,percent of total billed charges,999999999,8.1,18.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PIN, STEIN THREADED TRCR",0272,C1713,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,27.00 ,18.90 ,Aetna,"AETNA",979.38,308.7,fee schedule,999999999,8.1,979.38162,fee schedule,""
"HCHG PLUG, FOLEY CATH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, ENDO OTO HGM LASER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1020.00 ,714.00 ,Aetna,"AETNA",459.00,45,percent of total billed charges,999999999,306,714,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, ENT ORAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1250.00 ,875.00 ,Aetna,"AETNA",562.50,45,percent of total billed charges,999999999,375,875,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, LAP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1250.00 ,875.00 ,Aetna,"AETNA",562.50,45,percent of total billed charges,999999999,375,875,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, NEZHAT IRRI",0272,,,RC,,,FACILITY,OUTPATIENT,,,,227.00 ,158.90 ,Aetna,"AETNA",102.15,45,percent of total billed charges,999999999,68.1,158.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, SWISS LITHOCLAST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, VULCAN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, VULCAN TAC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1659.00 ,1161.30 ,Aetna,"AETNA",746.55,45,percent of total billed charges,999999999,497.7,1161.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PUMP SET, THROMBECT ANGIOJET",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1348.00 ,943.60 ,Aetna,"AETNA",606.60,45,percent of total billed charges,999999999,404.4,943.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PUNCH, AORTIC #4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,925.00 ,647.50 ,Aetna,"AETNA",416.25,45,percent of total billed charges,999999999,277.5,647.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RETRACTOR STAYS, SCOTT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,260.00 ,182.00 ,Aetna,"AETNA",117.00,45,percent of total billed charges,999999999,78,182,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG RETRACTOR, ENDOPADDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,754.00 ,527.80 ,Aetna,"AETNA",339.30,45,percent of total billed charges,999999999,226.2,527.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SCRAPER, MEMBRANE DIAMOND DUST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,629.00 ,440.30 ,Aetna,"AETNA",283.05,45,percent of total billed charges,999999999,188.7,440.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, CANALIARLUS INTUBATION-EYE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,555.00 ,388.50 ,Aetna,"AETNA",249.75,45,percent of total billed charges,999999999,166.5,388.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, CAPD TRANSFER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,168.00 ,117.60 ,Aetna,"AETNA",75.60,45,percent of total billed charges,999999999,50.4,117.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, CYSTO IRRIG Y TUR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,10.5,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, CYSTO IRRIG TUBING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,28.00 ,19.60 ,Aetna,"AETNA",12.60,45,percent of total billed charges,999999999,8.4,19.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, DILATATION VAN TECH 6-16FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1085.00 ,759.50 ,Aetna,"AETNA",488.25,45,percent of total billed charges,999999999,325.5,759.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, INTRO MICROPUNCTURE",0272,C1894,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,204.00 ,142.80 ,Aetna,"AETNA",254.03,308.7,fee schedule,999999999,61.2,254.02923,fee schedule,""
"HCHG SET, OSTEOCHONDRIAL HARVEST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2375.00 ,1662.50 ,Aetna,"AETNA",1068.75,45,percent of total billed charges,999999999,712.5,1662.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SET, TRIGEM GANGLION MICROCOMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1278.00 ,894.60 ,Aetna,"AETNA",575.10,45,percent of total billed charges,999999999,383.4,894.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHAVER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,280.00 ,196.00 ,Aetna,"AETNA",126.00,45,percent of total billed charges,999999999,84,196,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHEARS, ENDO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,536.00 ,375.20 ,Aetna,"AETNA",241.20,45,percent of total billed charges,999999999,160.8,375.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHEATH, ENDO-SCRUB",0272,A4270,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,241.00 ,168.70 ,Aetna,"AETNA",0.37,308.7,fee schedule,999999999,0.37044,168.7,fee schedule,""
"HCHG SHEATH, URET.ACCESS",0272,C1894,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,468.00 ,327.60 ,Aetna,"AETNA",254.03,308.7,fee schedule,999999999,140.4,327.6,fee schedule,""
"HCHG SHUNT, CAROTID",0272,,,RC,,,FACILITY,OUTPATIENT,,,,293.00 ,205.10 ,Aetna,"AETNA",131.85,45,percent of total billed charges,999999999,87.9,205.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHUNT, CSF CARDIAC/PERI CATH",0272,,,RC,,,FACILITY,OUTPATIENT,,,,614.00 ,429.80 ,Aetna,"AETNA",276.30,45,percent of total billed charges,999999999,184.2,429.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHUNT, PRUITT CAROTID T",0272,C2628,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,1603.00 ,1122.10 ,Aetna,"AETNA",1728.72,308.7,fee schedule,999999999,480.9,1728.72,fee schedule,""
"HCHG SOLUTION VISCOAT .5ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,360.00 ,252.00 ,Aetna,"AETNA",162.00,45,percent of total billed charges,999999999,108,252,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPECIMAN BAG, ENDO CATC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,427.00 ,298.90 ,Aetna,"AETNA",192.15,45,percent of total billed charges,999999999,128.1,298.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, BABY LAP W/O RINGS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,13.00 ,9.10 ,Aetna,"AETNA",5.85,45,percent of total billed charges,999999999,3.9,9.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, DRAIN SOF-WIK 4X4",0272,A6402,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, KENNEDY SINUS",0272,A6402,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,93.00 ,65.10 ,Aetna,"AETNA",41.85,45,percent of total billed charges,999999999,27.9,65.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, NASAL MRCL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, SURGIFOAM 100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,31.00 ,21.70 ,Aetna,"AETNA",13.95,45,percent of total billed charges,999999999,9.3,21.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, SURGIFOAM 12X7",0272,,,RC,,,FACILITY,OUTPATIENT,,,,43.00 ,30.10 ,Aetna,"AETNA",19.35,45,percent of total billed charges,999999999,12.9,30.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, TONSIL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,8.00 ,5.60 ,Aetna,"AETNA",3.60,45,percent of total billed charges,999999999,2.4,5.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SPONGE, WECKCEL SPEAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, CURVED",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, ENDO GIA UNIV",0272,,,RC,,,FACILITY,OUTPATIENT,,,,732.00 ,512.40 ,Aetna,"AETNA",329.40,45,percent of total billed charges,999999999,219.6,512.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, ENDO MULTIFIRE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1105.00 ,773.50 ,Aetna,"AETNA",497.25,45,percent of total billed charges,999999999,331.5,773.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, GIA MULTIFIRE 60/80",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, LINEAR 30",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, LINEAR 60",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1110.00 ,777.00 ,Aetna,"AETNA",499.50,45,percent of total billed charges,999999999,333,777,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, PCEEA PREMIUM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1638.00 ,1146.60 ,Aetna,"AETNA",737.10,45,percent of total billed charges,999999999,491.4,1146.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, PURSESTRING 65",0272,,,RC,,,FACILITY,OUTPATIENT,,,,358.00 ,250.60 ,Aetna,"AETNA",161.10,45,percent of total billed charges,999999999,107.4,250.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, ROTIC 30",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1130.00 ,791.00 ,Aetna,"AETNA",508.50,45,percent of total billed charges,999999999,339,791,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, ROTIC 55",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1143.00 ,800.10 ,Aetna,"AETNA",514.35,45,percent of total billed charges,999999999,342.9,800.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, ROTIC. FLEX",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1770.00 ,1239.00 ,Aetna,"AETNA",796.50,45,percent of total billed charges,999999999,531,1239,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, SKIN DISP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,44.00 ,30.80 ,Aetna,"AETNA",19.80,45,percent of total billed charges,999999999,13.2,30.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, TA 30/60",0272,,,RC,,,FACILITY,OUTPATIENT,,,,653.00 ,457.10 ,Aetna,"AETNA",293.85,45,percent of total billed charges,999999999,195.9,457.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, TA 45 4.8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, TA 90 35",0272,,,RC,,,FACILITY,OUTPATIENT,,,,671.00 ,469.70 ,Aetna,"AETNA",301.95,45,percent of total billed charges,999999999,201.3,469.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, ENDO MULTIFIRE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,618.00 ,432.60 ,Aetna,"AETNA",278.10,45,percent of total billed charges,999999999,185.4,432.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, GIA 90-3.8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,683.00 ,478.10 ,Aetna,"AETNA",307.35,45,percent of total billed charges,999999999,204.9,478.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, GIA MULTIFIRE 60/80",0272,,,RC,,,FACILITY,OUTPATIENT,,,,447.00 ,312.90 ,Aetna,"AETNA",201.15,45,percent of total billed charges,999999999,134.1,312.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, TA 45 4.8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,294.00 ,205.80 ,Aetna,"AETNA",132.30,45,percent of total billed charges,999999999,88.2,205.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, TA MULTIFIRE 30 3.5",0272,,,RC,,,FACILITY,OUTPATIENT,,,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,90,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, TA MULTIFIRE 30 4.8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,498.00 ,348.60 ,Aetna,"AETNA",224.10,45,percent of total billed charges,999999999,149.4,348.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER, TA55 35LD",0272,,,RC,,,FACILITY,OUTPATIENT,,,,334.00 ,233.80 ,Aetna,"AETNA",150.30,45,percent of total billed charges,999999999,100.2,233.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, TA-55 4.8",0272,,,RC,,,FACILITY,OUTPATIENT,,,,361.00 ,252.70 ,Aetna,"AETNA",162.45,45,percent of total billed charges,999999999,108.3,252.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, UNIV ROTIC 45 2.0",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1003.00 ,702.10 ,Aetna,"AETNA",451.35,45,percent of total billed charges,999999999,300.9,702.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, UNIV. ROTIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,955.00 ,668.50 ,Aetna,"AETNA",429.75,45,percent of total billed charges,999999999,286.5,668.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRYKER BRUSH FEMORAL CANAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRYKER IRRIG SET HC W/TUBING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,222.00 ,155.40 ,Aetna,"AETNA",99.90,45,percent of total billed charges,999999999,66.6,155.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STRYKER TIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SURGICLIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,330.00 ,231.00 ,Aetna,"AETNA",148.50,45,percent of total billed charges,999999999,99,231,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SURG-I-LOOP, MAXI (BLUE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SURG-I-LOOP, MINI (BLUE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,12.00 ,8.40 ,Aetna,"AETNA",5.40,45,percent of total billed charges,999999999,3.6,8.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SURG-I-LOOP, SUPER MAXI (BLUE)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE GUIDE, VALVE REPLACEMENT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,422.00 ,295.40 ,Aetna,"AETNA",189.90,45,percent of total billed charges,999999999,126.6,295.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE LASSO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,647.00 ,452.90 ,Aetna,"AETNA",291.15,45,percent of total billed charges,999999999,194.1,452.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE PASSER, CONCEPT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,366.00 ,256.20 ,Aetna,"AETNA",164.70,45,percent of total billed charges,999999999,109.8,256.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE PASSER, KNOT PUSHER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,459.00 ,321.30 ,Aetna,"AETNA",206.55,45,percent of total billed charges,999999999,137.7,321.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE, CAPIO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,137.00 ,95.90 ,Aetna,"AETNA",61.65,45,percent of total billed charges,999999999,41.1,95.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE, E PACK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,453.00 ,317.10 ,Aetna,"AETNA",203.85,45,percent of total billed charges,999999999,135.9,317.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE, MONODEK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,138.00 ,96.60 ,Aetna,"AETNA",62.10,45,percent of total billed charges,999999999,41.4,96.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SYRINGE, DISP EAR BULB",0272,,,RC,,,FACILITY,OUTPATIENT,,,,5.00 ,3.50 ,Aetna,"AETNA",2.25,45,percent of total billed charges,999999999,1.5,3.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SYRINGE, INFLATION FOR KYPHO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,684.00 ,478.80 ,Aetna,"AETNA",307.80,45,percent of total billed charges,999999999,205.2,478.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TACKER, W/HANDLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1336.00 ,935.20 ,Aetna,"AETNA",601.20,45,percent of total billed charges,999999999,400.8,935.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TIES, VESSEL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,20.00 ,14.00 ,Aetna,"AETNA",9.00,45,percent of total billed charges,999999999,6,14,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TIP POLISHER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,75.00 ,52.50 ,Aetna,"AETNA",33.75,45,percent of total billed charges,999999999,22.5,52.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TIP, PHACO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,420.00 ,294.00 ,Aetna,"AETNA",189.00,45,percent of total billed charges,999999999,126,294,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRANSDUCER, ADULT DBL KIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,153.00 ,107.10 ,Aetna,"AETNA",68.85,45,percent of total billed charges,999999999,45.9,107.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRANSDUCER, OXISENSOR DIGIT 20",0272,A4606,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,66.00 ,46.20 ,Aetna,"AETNA",7.72,308.7,fee schedule,999999999,7.7175,46.2,fee schedule,""
"HCHG TRAY, EPIDURAL SINGLE SHOT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRAY, MANOMETER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",22.05,45,percent of total billed charges,999999999,14.7,34.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TRAY, PERC INTRO SHEATH 8.5FR",0272,C1894,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,158.00 ,110.60 ,Aetna,"AETNA",254.03,308.7,fee schedule,999999999,47.4,254.02923,fee schedule,""
"HCHG TRAY, SADDLE BLOCK 22GA",0272,,,RC,,,FACILITY,OUTPATIENT,,,,84.00 ,58.80 ,Aetna,"AETNA",37.80,45,percent of total billed charges,999999999,25.2,58.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, BLUNTPORT 12MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,194.00 ,135.80 ,Aetna,"AETNA",87.30,45,percent of total billed charges,999999999,58.2,135.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SEPARATOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,151.00 ,105.70 ,Aetna,"AETNA",67.95,45,percent of total billed charges,999999999,45.3,105.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SEPARATOR 12X100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,197.00 ,137.90 ,Aetna,"AETNA",88.65,45,percent of total billed charges,999999999,59.1,137.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SHIELD OBTU 5X100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,144.00 ,100.80 ,Aetna,"AETNA",64.80,45,percent of total billed charges,999999999,43.2,100.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SMTH CAN&SEAL 5",0272,,,RC,,,FACILITY,OUTPATIENT,,,,54.00 ,37.80 ,Aetna,"AETNA",24.30,45,percent of total billed charges,999999999,16.2,37.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SMTH CAN&SEAL11",0272,,,RC,,,FACILITY,OUTPATIENT,,,,105.00 ,73.50 ,Aetna,"AETNA",47.25,45,percent of total billed charges,999999999,31.5,73.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SMTH CAN&SEAL12",0272,,,RC,,,FACILITY,OUTPATIENT,,,,101.00 ,70.70 ,Aetna,"AETNA",45.45,45,percent of total billed charges,999999999,30.3,70.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, STEP 11MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,466.00 ,326.20 ,Aetna,"AETNA",209.70,45,percent of total billed charges,999999999,139.8,326.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, STEP 12MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,524.00 ,366.80 ,Aetna,"AETNA",235.80,45,percent of total billed charges,999999999,157.2,366.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, STEP 5MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,415.00 ,290.50 ,Aetna,"AETNA",186.75,45,percent of total billed charges,999999999,124.5,290.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, SURGIPORT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,359.00 ,251.30 ,Aetna,"AETNA",161.55,45,percent of total billed charges,999999999,107.7,251.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,101.00 ,70.70 ,Aetna,"AETNA",45.45,45,percent of total billed charges,999999999,30.3,70.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, THRD BLADED",0272,,,RC,,,FACILITY,OUTPATIENT,,,,188.00 ,131.60 ,Aetna,"AETNA",84.60,45,percent of total billed charges,999999999,56.4,131.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, THRD CAN&SEAL 5X100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,52.00 ,36.40 ,Aetna,"AETNA",23.40,45,percent of total billed charges,999999999,15.6,36.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, THRD CAN&SEAL11X100",0272,,,RC,,,FACILITY,OUTPATIENT,,,,101.00 ,70.70 ,Aetna,"AETNA",45.45,45,percent of total billed charges,999999999,30.3,70.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, THRD CANN&SEAL 5X55",0272,,,RC,,,FACILITY,OUTPATIENT,,,,54.00 ,37.80 ,Aetna,"AETNA",24.30,45,percent of total billed charges,999999999,16.2,37.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, THRD SPIKE 5X55",0272,,,RC,,,FACILITY,OUTPATIENT,,,,85.00 ,59.50 ,Aetna,"AETNA",38.25,45,percent of total billed charges,999999999,25.5,59.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, VERSAPORT 12MM LONG",0272,,,RC,,,FACILITY,OUTPATIENT,,,,647.00 ,452.90 ,Aetna,"AETNA",291.15,45,percent of total billed charges,999999999,194.1,452.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TROCAR, W/SHIELDED OBTUR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,151.00 ,105.70 ,Aetna,"AETNA",67.95,45,percent of total billed charges,999999999,45.3,105.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, CHEST 28FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,99.00 ,69.30 ,Aetna,"AETNA",44.55,45,percent of total billed charges,999999999,29.7,69.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, CHEST 32FR ANGLED",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,61.00 ,42.70 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,18.3,42.7,fee schedule,""
"HCHG TUBE, CHEST 32FR ST",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,42.00 ,29.40 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,12.6,34.2657,fee schedule,""
"HCHG TUBE, CHEST 36FR ANGLED",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,61.00 ,42.70 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,18.3,42.7,fee schedule,""
"HCHG TUBE, CHEST 36FR ST",0272,C1729,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,42.00 ,29.40 ,Aetna,"AETNA",34.27,308.7,fee schedule,999999999,12.6,34.2657,fee schedule,""
"HCHG TUBE, ET CUFFED 6.5 HI-LO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, ET CUFFED 7.0 HI-LO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, ET CUFFED 7.5 HI-LO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, ET CUFFED 8.0 HI-LO",0272,,,RC,,,FACILITY,OUTPATIENT,,,,15.00 ,10.50 ,Aetna,"AETNA",6.75,45,percent of total billed charges,999999999,4.5,10.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBE, LUKI TRAP STERILE DISP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,35.00 ,24.50 ,Aetna,"AETNA",15.75,45,percent of total billed charges,999999999,10.5,24.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, ARTHREX PATIENT REDEUCE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,146.00 ,102.20 ,Aetna,"AETNA",65.70,45,percent of total billed charges,999999999,43.8,102.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, ARTHREX PUMP REDEUCE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,330.00 ,231.00 ,Aetna,"AETNA",148.50,45,percent of total billed charges,999999999,99,231,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, ASPIRATION (LIPO)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,54.00 ,37.80 ,Aetna,"AETNA",24.30,45,percent of total billed charges,999999999,16.2,37.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, CDIS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,733.00 ,513.10 ,Aetna,"AETNA",329.85,45,percent of total billed charges,999999999,219.9,513.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, CO-SET COLD INJ",0272,,,RC,,,FACILITY,OUTPATIENT,,,,70.00 ,49.00 ,Aetna,"AETNA",31.50,45,percent of total billed charges,999999999,21,49,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, D & E COLLECTION SET",0272,,,RC,,,FACILITY,OUTPATIENT,,,,966.00 ,676.20 ,Aetna,"AETNA",434.70,45,percent of total billed charges,999999999,289.8,676.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, ENDOSCRUB II",0272,,,RC,,,FACILITY,OUTPATIENT,,,,186.00 ,130.20 ,Aetna,"AETNA",83.70,45,percent of total billed charges,999999999,55.8,130.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, FILTER STRYKER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,56.00 ,39.20 ,Aetna,"AETNA",25.20,45,percent of total billed charges,999999999,16.8,39.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, HYDRO THERMABLATOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3000.00 ,2100.00 ,Aetna,"AETNA",1350.00,45,percent of total billed charges,999999999,900,2100,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, HYSTEROSCOPY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,584.00 ,408.80 ,Aetna,"AETNA",262.80,45,percent of total billed charges,999999999,175.2,408.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, IRRIG BIPOLAR 'MALIS'",0272,,,RC,,,FACILITY,OUTPATIENT,,,,262.00 ,183.40 ,Aetna,"AETNA",117.90,45,percent of total billed charges,999999999,78.6,183.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, IRRIG. STR. SHOT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,95.00 ,66.50 ,Aetna,"AETNA",42.75,45,percent of total billed charges,999999999,28.5,66.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, PUMP 3M (ORTHO)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,356.00 ,249.20 ,Aetna,"AETNA",160.20,45,percent of total billed charges,999999999,106.8,249.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG TUBING, SMALL JOINT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,576.00 ,403.20 ,Aetna,"AETNA",259.20,45,percent of total billed charges,999999999,172.8,403.2,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG UTERINE MANIPULATOR RUMI",0272,,,RC,,,FACILITY,OUTPATIENT,,,,217.00 ,151.90 ,Aetna,"AETNA",97.65,45,percent of total billed charges,999999999,65.1,151.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG VEIN STRIPPER, DISP X-RAY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,112.00 ,78.40 ,Aetna,"AETNA",50.40,45,percent of total billed charges,999999999,33.6,78.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG VISCERA (FISH) RETAINER MED",0272,,,RC,,,FACILITY,OUTPATIENT,,,,105.00 ,73.50 ,Aetna,"AETNA",47.25,45,percent of total billed charges,999999999,31.5,73.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG WIRE, AMPLATZ EXTRA STIFF",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,160.00 ,112.00 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,48,170.18631,fee schedule,""
"HCHG WIRE, GLIDE VC FILTER",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,383.00 ,268.10 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,114.9,268.1,fee schedule,""
"HCHG WIRE, GLIDE-ANGLED",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,296.00 ,207.20 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,88.8,207.2,fee schedule,""
"HCHG WIRE, GLIDE-MAGIC",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,360.00 ,252.00 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,108,252,fee schedule,""
"HCHG WIRE, GUIDE",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,80.00 ,56.00 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,24,170.18631,fee schedule,""
"HCHG WIRE, GUIDE (ANES)",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,84.00 ,58.80 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,25.2,170.18631,fee schedule,""
"HCHG WIRE, GUIDE 2.5 DRILL TIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,309.00 ,216.30 ,Aetna,"AETNA",139.05,45,percent of total billed charges,999999999,92.7,216.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG WIRE, GUIDE EMRLD",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,49.00 ,34.30 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,14.7,170.18631,fee schedule,""
"HCHG WIRE, GUIDE SENSOR",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,302.00 ,211.40 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,90.6,211.4,fee schedule,""
"HCHG WIRE, GUIDE TAPER",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,571.00 ,399.70 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,170.18631,399.7,fee schedule,""
"HCHG WIRE, GUIDE ZEBRA",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,364.00 ,254.80 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,109.2,254.8,fee schedule,""
"HCHG WIRE, K-150MM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,58.00 ,40.60 ,Aetna,"AETNA",26.10,45,percent of total billed charges,999999999,17.4,40.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG WIRE, K-5M DBL END",0272,,,RC,,,FACILITY,OUTPATIENT,,,,19.00 ,13.30 ,Aetna,"AETNA",8.55,45,percent of total billed charges,999999999,5.7,13.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG WIRE, STRYKER IMF",0272,,,RC,,,FACILITY,OUTPATIENT,,,,52.00 ,36.40 ,Aetna,"AETNA",23.40,45,percent of total billed charges,999999999,15.6,36.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG WIRE, SURG STEEL (ORAL)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,29.00 ,20.30 ,Aetna,"AETNA",13.05,45,percent of total billed charges,999999999,8.7,20.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATH, COUDE 24FR",0272,A4352,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,25.00 ,17.50 ,Aetna,"AETNA",11.25,45,percent of total billed charges,999999999,7.1,17.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PAD, TRAC W/ TUBING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,120.00 ,84.00 ,Aetna,"AETNA",54.00,45,percent of total billed charges,999999999,36,84,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CATHETER, TROCAR 20FR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,99.00 ,69.30 ,Aetna,"AETNA",44.55,45,percent of total billed charges,999999999,29.7,69.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE PLASTIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,45.00 ,31.50 ,Aetna,"AETNA",20.25,45,percent of total billed charges,999999999,13.5,31.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE EYE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,79.00 ,55.30 ,Aetna,"AETNA",35.55,45,percent of total billed charges,999999999,23.7,55.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE CV",0272,,,RC,,,FACILITY,OUTPATIENT,,,,91.00 ,63.70 ,Aetna,"AETNA",40.95,45,percent of total billed charges,999999999,27.3,63.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE GENERAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,30.00 ,21.00 ,Aetna,"AETNA",13.50,45,percent of total billed charges,999999999,9,21,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE, SOFT TIP STR. 50.01",0272,,,RC,,,FACILITY,OUTPATIENT,,,,83.00 ,58.10 ,Aetna,"AETNA",37.35,45,percent of total billed charges,999999999,24.9,58.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BONE PUTTY HEMOSTATIC (59)",0272,,,RC,,,FACILITY,OUTPATIENT,,,,354.00 ,247.80 ,Aetna,"AETNA",159.30,45,percent of total billed charges,999999999,106.2,247.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DURASEAL SEALANT SYSTEM 5ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2500.00 ,1750.00 ,Aetna,"AETNA",1125.00,45,percent of total billed charges,999999999,750,1750,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG BALLOON, INTRA-AORTIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2541.00 ,1778.70 ,Aetna,"AETNA",1143.45,45,percent of total billed charges,999999999,762.3,1778.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG FORCEP, BIPO CUT PK 5MM/45CM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1558.00 ,1090.60 ,Aetna,"AETNA",701.10,45,percent of total billed charges,999999999,467.4,1090.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SHEATH, SHARP SITE 30 DEGREE",0272,A4270,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,294.00 ,205.80 ,Aetna,"AETNA",0.37,308.7,fee schedule,999999999,0.37044,205.8,fee schedule,""
"HCHG TWIST DRILL W/AO FITTING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG KIT, NOVASURE ENDOMETRIAL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3285.00 ,2299.50 ,Aetna,"AETNA",1478.25,45,percent of total billed charges,999999999,985.5,2299.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, GASTRIC BANDING",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1338.00 ,936.60 ,Aetna,"AETNA",602.10,45,percent of total billed charges,999999999,401.4,936.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, LAP CHOLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,213.00 ,149.10 ,Aetna,"AETNA",95.85,45,percent of total billed charges,999999999,63.9,149.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, GENERAL EYE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,312.00 ,218.40 ,Aetna,"AETNA",140.40,45,percent of total billed charges,999999999,93.6,218.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, ENT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,168.00 ,117.60 ,Aetna,"AETNA",75.60,45,percent of total billed charges,999999999,50.4,117.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, EAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,238.00 ,166.60 ,Aetna,"AETNA",107.10,45,percent of total billed charges,999999999,71.4,166.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, BREAST",0272,,,RC,,,FACILITY,OUTPATIENT,,,,325.00 ,227.50 ,Aetna,"AETNA",146.25,45,percent of total billed charges,999999999,97.5,227.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, HAND",0272,,,RC,,,FACILITY,OUTPATIENT,,,,252.00 ,176.40 ,Aetna,"AETNA",113.40,45,percent of total billed charges,999999999,75.6,176.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, TOTAL HIP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,729.00 ,510.30 ,Aetna,"AETNA",328.05,45,percent of total billed charges,999999999,218.7,510.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, TOTAL KNEE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,450.00 ,315.00 ,Aetna,"AETNA",202.50,45,percent of total billed charges,999999999,135,315,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, KNEE ARTHROSCOPY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,312.00 ,218.40 ,Aetna,"AETNA",140.40,45,percent of total billed charges,999999999,93.6,218.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, SHOULDER ARTHROSCOPY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,321.00 ,224.70 ,Aetna,"AETNA",144.45,45,percent of total billed charges,999999999,96.3,224.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, MUSCLE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,269.00 ,188.30 ,Aetna,"AETNA",121.05,45,percent of total billed charges,999999999,80.7,188.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, D&C",0272,,,RC,,,FACILITY,OUTPATIENT,,,,123.00 ,86.10 ,Aetna,"AETNA",55.35,45,percent of total billed charges,999999999,36.9,86.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, MINOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,147.00 ,102.90 ,Aetna,"AETNA",66.15,45,percent of total billed charges,999999999,44.1,102.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROBE, PRASS STANDARD",0272,,,RC,,,FACILITY,OUTPATIENT,,,,534.00 ,373.80 ,Aetna,"AETNA",240.30,45,percent of total billed charges,999999999,160.2,373.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SCISSOR HANDLE, HARMONIC ACE",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1943.00 ,1360.10 ,Aetna,"AETNA",874.35,45,percent of total billed charges,999999999,582.9,1360.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PACK, MAJOR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,221.00 ,154.70 ,Aetna,"AETNA",99.45,45,percent of total billed charges,999999999,66.3,154.7,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDEWIRE, SYNTHES",0272,C1769,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,145.00 ,101.50 ,Aetna,"AETNA",170.19,308.7,fee schedule,999999999,43.5,170.18631,fee schedule,""
"HCHG SURGIFLO HEMOSTATIC MATRIX 6ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,584.00 ,408.80 ,Aetna,"AETNA",262.80,45,percent of total billed charges,999999999,175.2,408.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT, SURGICEL 4X4",0272,,,RC,,,FACILITY,OUTPATIENT,,,,752.00 ,526.40 ,Aetna,"AETNA",338.40,45,percent of total billed charges,999999999,225.6,526.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SEALANT-FIBRIN EVICEL 2 ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1028.00 ,719.60 ,Aetna,"AETNA",462.60,45,percent of total billed charges,999999999,308.4,719.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SEALANT-FIBRIN EVICEL 5 ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2367.00 ,1656.90 ,Aetna,"AETNA",1065.15,45,percent of total billed charges,999999999,710.1,1656.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG APPLICATOR, EVICEL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,228.00 ,159.60 ,Aetna,"AETNA",102.60,45,percent of total billed charges,999999999,68.4,159.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLES, ETHICON ECR60",0272,,,RC,,,FACILITY,OUTPATIENT,,,,789.00 ,552.30 ,Aetna,"AETNA",355.05,45,percent of total billed charges,999999999,236.7,552.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INSERT, OFF-PUMP",0272,,,RC,,,FACILITY,OUTPATIENT,,,,300.00 ,210.00 ,Aetna,"AETNA",135.00,45,percent of total billed charges,999999999,90,210,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PROTECTION CAP, EXFX",0272,,,RC,,,FACILITY,OUTPATIENT,,,,24.00 ,16.80 ,Aetna,"AETNA",10.80,45,percent of total billed charges,999999999,7.2,16.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG MANIPULATOR, UTRN DAVINCI",0272,,,RC,,,FACILITY,OUTPATIENT,,,,493.00 ,345.10 ,Aetna,"AETNA",221.85,45,percent of total billed charges,999999999,147.9,345.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CANNULA, HIP TROCAR",0272,,,RC,,,FACILITY,OUTPATIENT,,,,152.00 ,106.40 ,Aetna,"AETNA",68.40,45,percent of total billed charges,999999999,45.6,106.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, INTERTAN SHORT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,668.00 ,467.60 ,Aetna,"AETNA",300.60,45,percent of total billed charges,999999999,200.4,467.6,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DRILL BIT, INTERTAN LONG",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE PIN, CANNULATED 6.5",0272,,,RC,,,FACILITY,OUTPATIENT,,,,274.00 ,191.80 ,Aetna,"AETNA",123.30,45,percent of total billed charges,999999999,82.2,191.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER ABSORBATACK FIXTN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2512.00 ,1758.40 ,Aetna,"AETNA",1130.40,45,percent of total billed charges,999999999,753.6,1758.4,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG EXTRACTOR, TRIGEN NAIL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1029.00 ,720.30 ,Aetna,"AETNA",463.05,45,percent of total billed charges,999999999,308.7,720.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DEVICE, LIGASURE V SEALER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2254.00 ,1577.80 ,Aetna,"AETNA",1014.30,45,percent of total billed charges,999999999,676.2,1577.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG DEVICE, LIGASURE IMPACT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,2730.00 ,1911.00 ,Aetna,"AETNA",1228.50,45,percent of total billed charges,999999999,819,1911,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG PUMP, ON-Q 400ML",0272,,,RC,,,FACILITY,OUTPATIENT,,,,900.00 ,630.00 ,Aetna,"AETNA",405.00,45,percent of total billed charges,999999999,270,630,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG INTRO, ON-Q TUNLR SHEATH",0272,C1894,,RC,HCPCS,,FACILITY,OUTPATIENT,,,,177.00 ,123.90 ,Aetna,"AETNA",254.03,308.7,fee schedule,999999999,53.1,254.02923,fee schedule,""
"HCHG ACROBAT VACUUM POSITIONER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3150.00 ,2205.00 ,Aetna,"AETNA",1417.50,45,percent of total billed charges,999999999,945,2205,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG STAPLER,SKIN 35W PREMIUM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,164.00 ,114.80 ,Aetna,"AETNA",73.80,45,percent of total billed charges,999999999,49.2,114.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SEALER,TISSUELINK",0272,,,RC,,,FACILITY,OUTPATIENT,,,,8255.00 ,5778.50 ,Aetna,"AETNA",3714.75,45,percent of total billed charges,999999999,2476.5,5778.5,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG NEEDLE ELECTRODE KIT",0272,,,RC,,,FACILITY,OUTPATIENT,,,,3813.00 ,2669.10 ,Aetna,"AETNA",1715.85,45,percent of total billed charges,999999999,1143.9,2669.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE, QUILL",0272,,,RC,,,FACILITY,OUTPATIENT,,,,247.00 ,172.90 ,Aetna,"AETNA",111.15,45,percent of total billed charges,999999999,74.1,172.9,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLIP SUTURE, LAPRA-TY",0272,,,RC,,,FACILITY,OUTPATIENT,,,,319.00 ,223.30 ,Aetna,"AETNA",143.55,45,percent of total billed charges,999999999,95.7,223.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE, OHS",0272,,,RC,,,FACILITY,OUTPATIENT,,,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG SUTURE,FIBERTAPE #2",0272,,,RC,,,FACILITY,OUTPATIENT,,,,570.00 ,399.00 ,Aetna,"AETNA",256.50,45,percent of total billed charges,999999999,171,399,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG GUIDE PIN,OIC",0272,,,RC,,,FACILITY,OUTPATIENT,,,,180.00 ,126.00 ,Aetna,"AETNA",81.00,45,percent of total billed charges,999999999,54,126,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG CLOSURE PRINEO SKIN",0272,,,RC,,,FACILITY,OUTPATIENT,,,,864.00 ,604.80 ,Aetna,"AETNA",388.80,45,percent of total billed charges,999999999,259.2,604.8,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT POWDER-5GRAM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,1273.00 ,891.10 ,Aetna,"AETNA",572.85,45,percent of total billed charges,999999999,381.9,891.1,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG HEMOSTAT POWDER-3GRAM",0272,,,RC,,,FACILITY,OUTPATIENT,,,,969.00 ,678.30 ,Aetna,"AETNA",436.05,45,percent of total billed charges,999999999,290.7,678.3,percent of total billed charges,"45% of Billed Charges for drugs not listed on fee schedule"
"HCHG APPLICATOR-HEMOSTAT POWDER",0272,,,RC,,,FACILITY,OUTPATIENT,,,,91.00 ,63.70 ,Aetna,"AETNA",40.95,45,percent of total billed charges,999999999,27.3,63.7,percent of total billed charges,"45% of Billed Charges for drugs not liste